Retirada de projetil de arma de fogo alojado em assoalho infraorbitário com preservação do globo ocular: relato de caso / Removal of a firearm projectile lodged in the infraorbital floor with preservation of the eyeball: case report

Objetivo: relatar um caso de ferimento por arma de fogo (FAF), com projétil balístico alojado em região infraorbitária à esquerda, relatando tratamento cirúrgico de urgência para exérese do projetil por acesso subciliar. Relato do caso: Paciente do gênero masculino, 18 anos, foi encaminhado ao pronto socorro do Hospital Universitário por conta de ferimento por arma de fogo. Ao exame clínico, foi verificado discreto aumento de volume em região cervical e hemiface à esquerda, ausência de sangramento em face; presença de limitação para infraversão de olho esquerdo. O orifício de entrada do projetil foi identificado em região de tórax superior posterior à esquerda; após realização de tomografia de face, confirmou-se fratura de assoalho orbitário esquerdo, assim como projétil alojado abaixo do globo ocular. O ato cirúrgico foi realizado com caráter de urgência pela equipe de Cirurgia e Traumatologia Bucomaxilofacial. Discussão: estudos descrevem a importância da realização do adequado manejo de lesões traumáticas decorrentes de FAF seguido de remoção do projetil com urgência, visto que as complicações ao postergar o tempo cirúrgico só agravam o quadro clínico do paciente, além das afecções futuras que podem surgir com o decorrer da resolução do caso clínico. Conclusão: ratifica-se a importância da multidisciplinariedade entres as clínicas médicas, assim como, o correto manejo do paciente traumatizado, baseado nos critérios que conduzem o plano de tratamento.(AU)

Aim: to report a case of gunshot wound, with ballistic projectile lodged in the left infraorbital region, reporting emergency surgical treatment for projectile exeresis by subciliary access. Case Report: An 18-year-old male patient was referred to the emergency department of the University Hospital due to a gunshot wound. On clinical examination, it was found slight increase in volume in the cervical region and left hemiface, absence of bleeding in the face; presence of limitation to infraversion of the left eye. The entrance hole of the projectile was identified in the posterior left upper thorax region; after a tomography of the face, a fracture of the left orbital floor was confirmed, as well as the projectile lodged below the eyeball. The surgery was urgently performed by the Oral and Maxillofacial Surgery team. Discussion: Studies describe the importance of performing the proper management of traumatic injuries resulting from FAF followed by removal of the projectile with urgency, since the complications to postpone the surgical time only aggravate the clinical picture of the patient, in addition to future problems that may arise with the resolution of the clinical case. Conclusion: the importance of multidisciplinarity among medical clinics is ratified, as well as the correct management of the traumatized patient, based on the criteria that lead to the treatment plan.(AU)

Tratamiento de las fracturas por herida de arma de fuego: revisión bibliográfica sistematizada / Treatment of gunshot wound fractures: systematic review of the literature / Tratamento de fraturas por arma de fogo: revisão bibliográfica sistematizada

Introducción: Las fracturas por heridas de arma de fuego son un motivo de consulta habitual en nuestro país. Existe gran variabilidad de conductas respecto a su tratamiento. El objetivo principal de este trabajo es analizar los distintos tratamientos y sus indicaciones. Materiales: Se realizó una revisión sistematizada de la literatura en las bases de datos Pubmed y Scielo. Se incluyeron artículos con fracturas por herida de arma de fuego en miembros superiores e inferiores, excluyendo la mano. Se analizó: tratamiento (ortopédico o quirúrgico), debridamiento, antibioticoterapia y complicaciones. Resultados: Se obtuvieron 19 artículos que cumplían los criterios de inclusión y exclusión. Los artículos tuvieron un Nivel de Evidencia tipo 2b, 3 y 4. Conclusiones: Los artículos analizados tienen un bajo nivel de evidencia. La fijación quirúrgica es variable y depende de la topografía ósea, la lesión de partes blandas y las lesiones asociadas. El debridamiento profundo está relacionado con mayores índices de infección. Las fracturas estables de tratamiento ortopédico no deberían debridarse ya que aumenta los índices de infección. Debería realizarse antibioticoterapia intravenosa inicial en todos los pacientes, la terapia posterior es discutida.

Introduction: Fractures due to gunshot wounds are a common reason for consultation in our country. There is great variability of conduct regarding its treatment. The main objective of this work is to analyze the different treatments and their indications. Materials: A systematic review of the literature was carried out in the Pubmed and Scielo databases. Articles with fractures due to gunshot wounds in the upper and lower limbs (excluding the hand) were included. We analyzed: treatment (orthopedic or surgical), debridement, antibiotic therapy and complications. Results: 19 articles were obtained that met the inclusion and exclusion criteria. The articles had a Level of Evidence type 2b, 3 and 4. Conclusions: The articles analyzed have a low level of evidence. Surgical fixation is variable and depends on bone topography, soft tissue injury, and associated injuries. Deep debridement is associated with higher rates of infection. Stable orthopedically treated fractures should not be debrided as this increases infection rates. Initial intravenous antibiotic therapy should be performed in all patients, subsequent therapy is discussed.

Introdução: As fraturas por ferimentos por arma de fogo são motivo comum de consulta em nosso país. Há grande variabilidade de conduta quanto ao seu tratamento. O objetivo principal deste trabalho é analisar os diferentes tratamentos e suas indicações. Materiais: Foi realizada revisão sistemática da literatura nas bases de dados Pubmed e Scielo. Foram incluídos artigos com fraturas por arma de fogo em membros superiores e inferiores, excluindo a mão. Foram analisados: tratamento (ortopédico ou cirúrgico), desbridamento, antibioticoterapia e complicações. Resultados: foram obtidos 19 artigos que atenderam aos critérios de inclusão e exclusão. Os artigos tinham Nível de Evidência tipo 2b, 3 e 4. Conclusões: Os artigos analisados ​​apresentam baixo nível de evidência. A fixação cirúrgica é variável e depende da topografia óssea, lesão de tecidos moles e lesões associadas. O desbridamento profundo está associado a maiores taxas de infecção. Fraturas estáveis ​​tratadas ortopedicamente não devem ser desbridadas, pois isso aumenta as taxas de infecção. A antibioticoterapia intravenosa inicial deve ser realizada em todos os pacientes, a terapia subsequente é discutida.

Multiple Brain Abscesses by an Air Gun Shot: A Case Report

Introduction Low-velocity penetrating brain injury is not prevalent. In some conditions such as childhood, and with the penetration of a pellet in weak spots of skull, low-velocity penetrating brain injury is expected; however, high-velocity projectiles have also been reported as the cause of severe brain injuries. One of the complications of penetrating brain injury is infection, in which different types ofmicroorganisms play a role. The Streptococcus genus is the leading cause of abscess formation in nontraumatic patients. Multiple brain abscesses are not common. Case Presentation A 10-year-old boy with penetrating brain injury caused by an air gun pellet, who developed signs and symptoms of high intracranial pressure 18 days after the trauma. After the imaging scans and the detection of multiple brain abscesses and severe brain edema, prompt surgical intervention was performed for all three lesions in a single operation. The culture of a pus specimen was positive for Streptococcus species, and, with adequate antibiotic therapy, the patient was discharged from the hospital in good condition. Conclusion Brain injurywith air gun shot is not prevalent. The penetration of a low-velocity air gun pellet in weak points of the skull (such as the orbit, the squamous portion of the temporal bone, and the cranial suture), specially in children, can cause significant brain injuries.

Management of spinal gunshot wound injuries / Manejo das lesões por arma de fogo na coluna vertebral / Manejo de lesiones por arma de fuego en la columna

ABSTRACT Objectives Elaborate a care protocol for spinal gunshot wounds (GSWs), based on the experience of more than fifteen years of treating this type of injury. Methods A retrospective cross-sectional analysis of the electronic medical record data of a tertiary hospital related to the treatment of spinal GSWs between January 2002 and January 2018. Results The management proposed was applied to 700 patients. Epidemiological data collected describes the population served. Conclusions An easy-to-use treatment flowchart was developed that, according to factors related to the neurological condition, projectile location, lesion stability and additional criteria, allows the objective determination of the best treatment option for each case. Level of evidence II; Retrospective Study.

RESUMO Objetivos Elaborar um protocolo de atendimento para ferimentos por arma de fogo (FAF) na coluna vertebral, com base na experiência de mais de quinze anos de atendimento desse tipo de lesão. Métodos Realizou-se uma análise transversal retrospectiva dos dados do prontuário eletrônico de um hospital terciário referentes ao atendimento de FAF na coluna vertebral entre janeiro de 2002 e janeiro de 2018. Resultados O manejo proposto foi aplicado a 700 pacientes. Os dados epidemiológicos coletados mostram a população atendida. Conclusões Foi elaborado um fluxograma de tratamento de uso fácil que, de acordo com fatores relacionados com o quadro neurológico, a localização do projétil, a estabilidade da lesão e critérios adicionais, permite determinar objetivamente a melhor opção de tratamento para cada caso. Nível de evidência II; Estudo Retrospectivo.

RESUMEN Objetivos Desarrollar un protocolo de atención a las heridas por arma de fuego (HAF) en la columna vertebral, basado en la experiencia de más de quince años en la atención a este tipo de lesiones. Métodos Se realizó un análisis transversal retrospectivo de los datos de la historia clínica electrónica de un hospital terciario sobre la atención en casos de HAF en la columna vertebral entre enero de 2002 y enero de 2018. Resultados Se aplicó el tratamiento propuesto a 700 pacientes. Los datos epidemiológicos recopilados muestran la población atendida. Conclusiones Se desarrolló un diagrama de flujo de tratamiento de fácil de usar que, de acuerdo a factores relacionados con la condición neurológica, ubicación del proyectil, estabilidad de la lesión y criterios adicionales, permite determinar objetivamente la mejor opción de tratamiento para cada caso. Nivel de evidencia II; Estudio Retrospectivo.

As marcas da violência por arma de fogo em face / The marks of gunshot wounds to the face

Resumo Introdução: Este artigo aborda a ocorrência de agravos à saúde em virtude de ferimentos na face por arma de fogo, entre os policiais militares, na Região Metropolitana do Estado do Rio de Janeiro, operados pela Clínica de Cirurgia e Traumatologia Bucomaxilofacial do Hospital Central da Polícia Militar. Objetivo: Identificar o perfil dos pacientes operados em decorrência de ferimentos na face por arma de fogo, a distribuição anatômica das fraturas maxilofaciais, as sequelas e complicações encontradas, as especialidades em saúde envolvidas na reabilitação desses pacientes, além de discutir sobre as repercussões sociais, emocionais e relativas ao desempenho do trabalho entre esses sujeitos. Método: Foi feito um estudo epidemiológico retrospectivo a partir de dados secundários referentes aos policiais militares operados no Hospital Central da Polícia Militar em decorrência de ferimentos por arma de fogo em face, de junho de 2003 a dezembro de 2017. Resultado: Durante o período estudado foram feitas 778 cirurgias em centro cirúrgico pelo serviço de Clínica de Cirurgia e Traumatologia Bucomaxilofacial no Hospital Central da Polícia Militar, 186 em decorrência de ferimentos por arma de fogo (23,9%). Todos os pacientes eram do sexo masculino e com média de 34,7 anos. A perda de segmento ósseo foi a sequela mais encontrada. O comprometimento estético facial e os relatos de insônia foram as repercussões tardias de impacto na saúde e no convívio social mais encontradas. Sobre as repercussões laborais do ferimento sofrido, o tempo médio de afastamento por licença de saúde para tratamento dos ferimentos maxilofaciais foi de 11,7 meses. Conclusão: O tratamento de pacientes vítimas de ferimentos por arma de fogo em face demanda múltiplas intervenções cirúrgicas e o envolvimento de diferentes especialidades da saúde para sua reabilitação. São necessários mais estudos que analisem qualitativamente o impacto desse tipo de traumatismo em face para a vida dos pacientes e seus desdobramentos sociais.

Fixação funcionalmente estável no tratamento de sequela de fratura cominutiva de mandíbula por PAF / Functionally stable fixation in the treatment of comminuted jaw fracture by firearm projectile

Introdução: em traumas de alta energia por projéteis de arma de fogo (PAF), pode ocorrer a cominuição da mandíbula. Quando não identificadas ou tratadas de maneira equivocada, essas injúrias podem comprometer a saúde do indivíduo, com graves complicações estéticas e funcionais. Objetivo: o objetivo deste trabalho é relatar um caso de tratamento cirúrgico de sequela de ferimento por arma de fogo com fratura cominutiva em região de sínfise mandibular. Relato do caso: paciente procurou o serviço de cirurgia e traumatologia bucomaxilofacial após tratamento cirúrgico insatisfatório de fratura mandibular por PAF. Observou-se clinicamente mobilidade em manipulação, exposição óssea e drenagem purulenta. Na tomografia, observou-se gap ósseo, descontinuidade na base mandibular e material de osteossíntese inadequado. Foi proposta uma abordagem cirúrgica para instalação de placa de reconstrução do sistema 2.4 mm. Em acompanhamento pós-operatório, o paciente evoluiu com abertura bucal funcional e satisfatória, sem mobilidade nos fragmentos ósseos, arcabouço mandibular restabelecido e adequado posicionamento do material de fixação. Considerações finais: os casos de cominuição óssea apresentam características individuais que devem ser levadas em consideração em seu manejo. Nesses casos, a escolha do material de fixação é fundamental para o sucesso terapêutico e o uso de prototipagem soma para uma condução satisfatória do caso, garantindo menor tempo cirúrgico e melhor adaptação da placa. (AU)

Introduction: in high energy traumas caused by firearm projectiles may occur comminutive mandibular fractures. When it is not identified or inappropriately treated, these injuries can compromisse the individual's health, with serious aesthetics and funcional complications. Objective: the aim of this study is report a case of surgical treatment of sequelae from firearm injury with comminutive fracture in the region of mandibular symphysis. Case report: patient sought the service of Oral and Maxillofacial Surgery and Traumatology after 1 month of unsatisfactory surgical treatment of a mandibular fracture caused by firearm projectile. Clinical examination revealed mobility to manipulation and bone exposure with purulent drainage. Computed tomography of the face shows bad fracture consolidation in the anterior region of the mandible with bone gap and discontinuity in the mandibular base and inadequate and poorly positioned osteosynthesis material. It was then proposed a new surgical approach with instalation of the reconstruction plate of 2.4mm locking system. In postoperative follow-up, the patient evolved with a functional and satisfactory mouth opening, with no mobility in bone fragments, restored mandibular framework and adequate positioning of the fixation material. Final considerations: the cases of comminutive bone fractures show particular features that should be considered in their handling. In these cases, the choice of the fixation material is critical to therapeutic success and the use of prototyping sum for a satisfactory conduction of the case, ensuring shorter surgical time and better adaptation of the plate.(AU)

Traumatismo torácico por arma de fuego / Thoracic trauma by firearms

Resumen Introducción: Los traumatismos torácicos por armas de fuego (TTAF) son cada vez más frecuentes. Objetivos: Describir características clínicas, morbilidad, mortalidad y la evolución a través del tiempo de hospitalizados por TTAF. Materiales y Método: Estudio analítico longitudinal. Período enero de 1981-diciembre de 2018. Revisión base de datos, protocolos prospectivos y fichas clínicas. Se utilizó planilla Microsoft Excel® y programa SPSS24® con chi cuadrado y de Mann-Whitney. Descripción de características de TTAF en pacientes hospitalizados y comparación por períodos. Se calcularon índices de gravedad del traumatismo (IGT): Injury Severity Score (ISS), Revised Trauma Score (RTS-T), Trauma Injury Severity Score (TRISS). Resultados: Total 4.306 pacientes hospitalizados por traumatismo torácico (TT), 205 (4,8%) hospitalizados por TTAF. Hombres: 188 (91,7%), edad promedio 28,8 ± 11,2 años, TTAF aislado 115 (56,1%), asociado a lesiones extratorácicas 90 (43,9%), de estos 55 (26,8%) se consideraron politraumatismos. Mecanismo: Agresión 193 (94,1%), autoagresión 11 (5,4%) y accidental 1 (0,5%). Lesiones y/o hallazgos torácicos más frecuentes: Hemotórax 127 (62,0%), neumotórax 96 (46,8%) y contusión pulmonar 51 (24,9%). Tratamiento definitivo: Pleurotomía 88 (42,9%), cirugía 71 (34,6%) y tratamiento médico 46 (22,4%). Mediana de hospitalización 7 días. Según IGT: ISS promedio 16,7 ± 11,7, RTS-T promedio 11,1 ± 2,1, TRISS promedio 9,6. Morbilidad: 44 (21,5%). Mortalidad: 14 (6,8%). En los diferentes períodos, se observó aumento de politraumatismos y TRISS, sin cambios en mortalidad. Discusión: La mayoría de los TTAF fueron aislados. Aproximadamente un tercio de los pacientes requirió cirugía. La mortalidad observada es menor a la esperada. Se observan cambios en los TTAF a través del tiempo.

Background: Thoracic trauma by firearms (TTF) are increasingly frequent. Aim: To describe clinical characteristics, morbidity and mortality and the evolution over time of patients hospitalized due TTF. Materials and Method: Longitudinal analytical study. Period January 1981 - December 2018. Database review, prospective protocols and clinical files. Microsoft Excel® spreadsheet and SPSS24® program with chi square and Mann-Whitney tests were used. Description of characteristics of TTF in hospitalized patients and comparison of TTF by periods. Trauma severity indexes (TSI) were calculated: Injury Severity Score (ISS), Revised Trauma Score (RTS-T), Trauma Injury Severity Score (TRISS). Results: Total: 4306 hospitalized patients due thoracic trauma (TT), 205 (4.8%) hospitalized due TTF. Men: 188 (91.7%), average age 28.8 ± 11.2 years, isolated TTF 115 (56.1%), associated with extrathoracic lesions 90 (43.9%), and of these 55 (26.8%) were considered polytraumatism. Mechanisms: aggression 193 (94.1%), self-harm 11 (5.4%) and accidental 1 (0.5%). Frequent thoracic injuries and/or findings: hemothorax 127 (62.0%), pneumothorax 96 (46.8%) and pulmonary contusion 51 (24.9%). Definitive treatment: Pleurotomy 88 (42.9%), surgery 71 (34.6%) and medical treatment 46 (22.4%). Median hospitalization 7 days. According TSI: Average ISS 16.7 ± 11.7, average RTS-T 11.1 ± 2.1, average TRISS 9.6. Morbidity: 44 (21.5%). Mortality: 14 (6.8%). There is an increase in polytraumatism and average TRISS, without changes in mortality. Discussion: The majority of TTF were isolated TT. Approximately one third of patients required surgery. The observed mortality is lower than expected. Changes in TTF were observed over time.

Fratura de mandíbula causada por projétil de arma de fogo: relato de caso / Mandible Fracture Caused by Firearm Projectile: Case Report

Introdução: A face é uma região exposta a diversos traumas que são causados por várias etiologias, dentre eles por projétil de arma de fogo que são a segunda maior causa de fraturas perdendo somente para os acidentes automobilísticos. As fraturas acometem com frequência a região mandibular, por ser um osso de destaque na face devido sua proeminência. O objetivo deste trabalho é elucidar uma fratura cominutiva na região de côndilo e colo mandibular causada por ferimento de arma de fogo e seu respectivo tratamento. Relato de Caso: Paciente de 25 anos, compareceu a um serviço de atendimento de cirurgia bucomaxilofacial vítima de um ferimento por arma de fogo. Após a realização dos exames de imagem constatou-se que o projétil estava alojado no pescoço da vítima, causando a fratura cominutiva o ramo e o côndilo mandibular do lado esquerdo. A paciente foi submetida a anestesia geral para realização da osteossíntese da fratura. Considerações finais: O diagnóstico e o tratamento são realizados por uma equipe multidisciplinar para que o tratamento seja o mais correto e efetivo, com finalidade de minimizar morbidades e mortalidades, já que os pacientes sobrevivem com sequelas permanentes quando o diagnóstico e o tratamento não são realizados de forma correta... (AU)

Introduction: The face is a region exposed to several traumas that are caused by several etiologies, among them a firearm projectile that is the second major cause of fractures losing only to automobile accidents. The fractures frequently affect the mandibular region, as it is a prominent bone in the face due to its prominence. The purpose of this study is to elucidate a comminuted fracture in the condyle and mandibular neck region caused by a firearm injury and its respective treatment. Case Report: A 25-year-old patient who attended a buccomaxillofacial surgery service as a victim of a gunshot wound. After imaging examinations it was found that the projectile was lodged in the victim's neck, causing the comminuted fracture of the branch and mandibular condyle on the left side. The patient underwent general anesthesia to perform the fracture osteosynthesis. Final considerations: Diagnosis and treatment are performed by a multidisciplinary team so that treatment is the most correct and effective, in order to minimize morbidities and mortalities, since patients survive with permanent sequelae when diagnosis and treatment are not performed correctly... (AU)

Trauma de vena cava en pacientes politraumatizados: experiencia en el Hospital Dr. Sótero del Río / Vena cava injury in politraumatized patients

Resumen Introducción Por su ubicación retroperitoneal, las lesiones de vena cava (LVC) son infrecuentes, presentándose en el contexto de un paciente con múltiples lesiones intraabdominales y en estado crítico. Objetivo Describir la experiencia de pacientes politraumatizados con LVC sometidos a resolución quirúrgica en Hospital Dr. Sotero del Río. Materiales y Método Análisis retrospectivo de 36 pacientes politraumatizados que dentro de la intervención quirúrgica se evidenció LVC en un período comprendido entre el 2010 y 2017. Resultados La serie estuvo compuesta por 36 pacientes, con LVC. El 88,8% son hombres, en el 97,2% el mecanismo de trauma es penetrante. Dentro de los niveles anatómicos vasculares más frecuentemente lesionados está la cava infrarrenal (41,6%), suprarrenal (25%), yuxtarrenal (22,2%) y la retrohepática e intratorácica (5,5% cada una). Las estructuras lesionadas asociadas más frecuentes fueron intestino delgado (38,8%), otros vasos de gran calibre (36,1%) y riñón (30,5%). Dentro del tipo de resolución quirúrgica, al 15,6% se realizó ligadura de vena cava y al 83,3% rafia simple. En 33,3% fue necesaria una toracotomía para el control vascular, siendo 2 de estas toracotomías resucitadoras. La media de hospitalización fue de 19,8 días. La mortalidad fue de 33,3%. Conclusiones De acuerdo a lo presentado, la alta mortalidad de LVC se encontró en el grupo de pacientes con inestabilidad hemodinámica y número de lesiones asociadas, en especial si involucran otros grandes vasos. Los esfuerzos para optimizar la supervivencia se deberían dirigir al traslado rápido prehospitalario y al entrenamiento de los cirujanos que enfrentan este tipo de lesiones.

Introduction For its retroperitoneal location, vena cava injuries are infrequent, however, occurring to a patient with multiple intra-abdominal injuries and in critical condition. Aim To describe the experience of polytraumatized patients with VCI who underwent surgical resolution in the Dr. Sotero del Rio hospital. Materials and Method Retrospective analysis of 36 polytraumatized patients that showed VCI during the surgical intervention within 2010 and 2017. Results The series was composed of 36 VCI patients. 88.8% are men, in 97.2% the mechanism of trauma is penetrating. Within the vascular anatomical levels, the most frequently injured are the infra-renal cava (41.6%) suprarenal (25%), yuxta-renal (22.2%) retro-hepatic and intrathoracic (5.5% each). The most frequent associated injured structures were the small intestine (38.8%) other vessels of large caliber (36.1%) and kidney (30.5%). In relation to the type of surgical resolution, 15.6% had a vena cava ligature and 83.3% simple raffia. In 33.3%, a thoracotomy was required for vascular control, two of them were resuscitative procedures. The average of hospitalization was 19.8 days. The mortality was 33.3%. Conclusions According to what presented, the high mortality of VCI was found in the group of patients with hemodynamic instability and the number of associated injuries; specially if other large vessels are involved. To optimize the survival, the efforts should be focused on a fast prehospital transfer and the training for surgeons who face this type of injury.

Gunshot injury to spine: An institutional experience of management and complications from a developing country / 中华创伤杂志(英文版)

PURPOSE@#Gunshot wounds are the second leading cause of spinal cord injuries. Surgical intervention for gunshot injury to the spine carries a high rate of complications. There is a scarcity of data on civilian gunshot injuries to the spine in Pakistan. Approximately 60 cases over the last 10 years have been recoded, with unusual presentation and neurological recovery. Thus it is imperative to fill this gap in data, by reviewing cases of civilian gunshot injuries to spine presenting at a tertiary care hospital (Aga Khan University Hospital, Karachi).@*METHODS@#This is a retrospective cohort study. Patients of all ages who presented to the emergency department of Aga Khan University Hospital, with gunshot injuries to spine between January 2005 and December 2016 were included in the study. Data were collected on neurological status (American Spinal Injury Association score was used for the initial and follow-up neurological assessment), extent of cord transection, motor and sensory deficits. The patients were further grouped into those with cord transection, and those with fractures of the bony spine but an intact spinal cord. These patients were then followed and the outcomes were recorded.@*RESULTS@#A total of 40 patients were identified. The mean ± SD of patients age was (30.9 ± 9.5) years. Of the 40 patients with gunshot wounds, 31 had the medical imaging performed at the facility, and hence they were included in this categorization. The remaining 9 patients were excluded from this additional grouping. Thirteen patients were managed surgically and 27 patients underwent the conservative management. The mean ± SD of follow-up was (8.7 ± 7.2) months. In our study, the thoracic spine was the most commonly injured region in gunshot injuries. Of the 31 patients with medical imaging performed at our institute, 17 (54.8%) had cord transection, of whom 8 (47%) ultimately developed paraplegia.@*CONCLUSION@#The prognosis of gunshot injuries to the spine can be varied depending on whether the spinal cord is intact or transected. This will help healthcare providers to plan the further management of the patient and counsel them accordingly.

Holmium Laser for Endoscopic Treatment of Benign Tracheal Stenosis

Abstract Introduction Laryngotracheal stenosis is a difficult problem with varied etiology and various treatment options. The holmium laser represents another tool for the treatment of benign tracheal stenosis. Objectives To determine the utility of holmium laser treatment for benign tracheal stenosis with regards to safety and efficacy. Methods This was a retrospective case study examining patients with benign tracheal stenosis from 1998-2016 who underwent holmium laser treatment. Determining the safety of this procedure was the primary goal, and complications were monitored as a surrogate of safety. Results A total of 123 patients who underwent holmium laser treatment for benign tracheal stenosis were identified. In total, 123 patients underwent 476 procedures, with follow-up ranging from 1 month to 14 years. No intraoperative or post-operative complications were identified as a direct result of the use of this particular laser. Conclusions The holmium laser is an effective and safe laser to use for tracheal stenosis treatment. It is a contact laser with a short acting distance, which reduces the risk of injury to distal airway structures. Given the favorable experience reported here, the holmium laser should be considered when tracheal surgery is attempted.

Heart injury with projectile lodged inside the heart

Abstract Penetrating heart injuries present high mortality rates. Increasing rates of urban violence have contributed to a significant rise in the number of heart injuries by firearm projectiles. Such injuries are associated with the highest mortality rates among penetrating cardiac injuries and may involve one or more cardiac chambers. We present the case of a police officer who, in an approach to five robbers, suffered a transfixed cardiac injury by firearm with the projectile having been lodged inside the right ventricle. This patient was successfully operated, 65 days after the injury, at our institution.

Embolization by Bullet Dislodged from the Heart

Abstract Embolization by a dislodged projectile is a rare complication that may occur in cases of gunshot cardiac injuries. We report a case of a firearm projectile cardiac injury that evolved, with dislocation of the projectile during cardiac surgery, into embolization of the right external carotid artery.

Extracción de un proyectil de arma de fuego de la cadera. luxación controlada anterior. reporte de dos casos / Bullet removal from the hip with a safe surgical anterior dislocation. report of two cases

El aumento de la prevalencia de las heridas por arma de fuego determina que sea cada vez más frecuente observar pacientes con fragmentos de proyectiles retenidos en el cuerpo. En la mayoría de los casos se consideran inertes para el paciente; sin embargo, está indicada su extracción cuando se encuentran alojados dentro de la articulación. De esta forma, se busca evitar el daño provocado por la sinovitis reactiva, la lesión condral y la posible progresión a una artrosis postraumática. El objetivo de este trabajo es presentar a dos pacientes con fragmentos de proyectiles alojados a nivel de la articulación coxofemoral, uno impactado sobre la cabeza femoral y el otro en el fondo acetabular. En ambos casos, se realizó una luxación controlada anterior a través de un abordaje posterolateral asociado a una osteotomía trocantérica según Ganz, para extraerlos; de esta manera, se logra una visualización completa de la cabeza femoral y un acceso al acetábulo, resguardando al máximo la perfusión vascular. Se evaluaron los resultados clínicos de ambos pacientes. Nivel de Evidencia: IV.

The increased prevalence of gunshot wounds makes it increasingly common to see patients with projectile fragments retained in the body. In most cases they are considered inert for the patient, but surgery is indicated to extract them, if they are located within the joint. In this way, we prevent damage from reactive synovitis, chondral injury and posible progression to post-traumatic osteoarthritis. The aim of this study is to report two cases in which the projectile fragments were at the level of the hip joint, one on the femoral head and the other in the acetabular fundus. In both patients, an anterior dislocation was performed through a postero-lateral approach associated with a trochanteric osteotomy described by Ganz. In this way a complete visualization of the femoral head and access to the acetabulum is achieved, thus protecting vascular perfusion. Clinical results were evaluated. Level of Evidence: IV.

Abordaje supraclavicular para el traumatismo vascular subclavio / Supraclavicular approach for subclavian vascular injuries

Introducción: la lesión traumática de los vasos subclavios no es frecuente. La causa fundamental está centrada en las heridas por armas de fuego y por objetos perforo-cortantes. La hemorragia o un hematoma en la zona de la base del cuello o tórax superior nos hacen pensar en esta lesión. El tratamiento depende principalmente de la estabilidad hemodinámica del paciente y los recursos disponibles. Este puede ser quirúrgico convencional o reparación endovascular. Objetivos: exponer los beneficios del abordaje supraclavicular para el tratamiento quirúrgico urgente de la lesión de vasos subclavios. Métodos: se realizó un estudio observacional, retro y prospectivo para recolectar la información de los pacientes atendidos por lesión traumática de vasos subclavios en nuestro centro, desde noviembre de 2011 hasta octubre de 2015. Resultados: de los pacientes intervenidos, 10 fueron hombres y una mujer. Todas las lesiones fueron por objetos perforo-cortantes. El tipo de lesión más frecuente fue la laceración de vena subclavia (63,6 por ciento). La vía de abordaje más utilizada fue la cervicotomía en tercio inferior con prolongación supraclavicular con clavicectomía y osteosíntesis ulterior. Hubo 3 fallecidos (27,3 por ciento). Conclusiones: la herida de vasos subclavios sucede más frecuente por objetos perforo-cortantes y tiene una alta mortalidad, la vía supraclavicular resultó la de mejor exposición para repararla. La prontitud del tratamiento fue la variable que más influyó en la morbilidad y mortalidad de esta afección(AU)

Introduction: traumatic injury of the subclavian vessels is rare. The main cause is focused on ballistic trauma and pierced-sharp objects. Bleeding or hematoma in the areas of the neck base or the upper chest lead us to think of this injury. Treatment depends mainly on the patient's hemodynamic stability and available resources. This may be conventional surgical or endovascular repair. Objectives: expose the benefits of supraclavicular approach to the urgent surgical treatment of the subclavian vessel lesions. Methods: a prospective and retro observational study was performed to gather information from patients treated for traumatic lesion of subclavian vessels in our hospital from November 2011 to October 2015. Results: out of the operated patients, 10 were men and one was woman. All lesions were drilled-sharp objects. The most common type of injury was the subclavian vein laceration (63.6 percent). The most commonly used approach was the cervicotomy in the lower third with supraclavicular clavicotomy clavicectomía and further extension with osteosynthesis. There were 3 deaths (27.3 percent). Conclusions: subclavian vessel wounds most frequently occur due to perforating-cutting objects and has a high mortality. The supraclavicular approach was the best access for repair. The promptness of treatment was the variable that most influenced the morbidity and mortality of this condition(AU)

Trauma no complexo craniomaxilofacial causado por projétil de arma de fogo - revisão de literatura e relato de caso / Trauma in craniomaxillofacial complex caused by firearm projectile - literature review and case report

Os traumatismos por projétil de arma de fogo são frequentes na prática bucomaxilofacial. As lesões causadas por esses projéteis e fragmentos constituem um desafio ao cirurgião, resultando em consequências estéticas e funcionais devastadoras. A atenção e a conduta terapêutica precisa visam à diminuição de complicações e sequelas. Vários fatores influenciam neste tipo de ferimento, tornando complexo o tratamento inicial e o definitivo pela imprevisibilidade desses. O objetivo deste trabalho é apresentar os aspectos técnicos do tratamento, através de uma revisão de literatura, bem como relatar um caso de trauma de face causado por projétil de arma de fogo, propondo a necessidade de um protocolo de atendimento baseado num maior conhecimento balístico e fisiopatológico objetivando diminuir a morbimortalidade.

Injuries caused by firearms projectiles are common in maxillofacial practice. These injuries constitute a challenge to the surgeon because they may have aesthetic and functional devastating consequences. Attention and precise therapy aim at reducing complications and sequelae. Several factors influence this type of injury, making complex initial care and definitive treatment more complex due to their unpredictability. The aim of this work was to present the technical aspects involved in the treatment, through a literature review and report the case of a patient with facial trauma caused by a firearm projectile; and suggests that a service protocol based on greater knowledge about ballistic pathophysiology is required in order to decrease the morbidity and mortality of this type of trauma.

Lesión severa de mano por proyectil de arma de fuego de alta energía con artrodesis del carpo e injerto sintético de hueso más fijadores externos: Reporte de un caso / Severe hand injury due to a high-energy gunshot projectile treated with arthrodesis of the carpus, synthetic bone graft and external fixators.: Case report

Antecedentes: La incidencia de heridas por proyectil de arma de fuego en mano de pacientes civiles se ha incrementado en los últimos años, lo cual es causa de incapacidades prolongadas o definitivas con un impacto personal, social y económico. Las lesiones severas de mano incluyen: afección del arco palmar mayor, fractura de dos o más huesos del carpo, luxaciones palmares irreductibles, fracturas articulares de radio distal y lesiones neurovasculares, los cuales requieren de múltiples procedimientos quirúrgicos para el manejo de tejidos blandos y musculoesqueléticos. Métodos: Se describe el reporte de un paciente con fractura de los huesos del carpo derecho, expuestos grados IIIB de Gustillo y Anderson por proyectil de arma de fuego, el cual fue tratado con artrodesis del carpo mediante injerto sintético, fijación externa y rotación de colgajo fasciocutáneo. Resultados: Paciente que fue sometido a tratamiento quirúrgico de la lesión del carpo consistente en fractura de todos los huesos del carpo, expuestos grados IIIB de Gustillo y Anderson por proyectil de arma de fuego quien fue sometido a tratamiento quirúrgico mediante artrodesis del carpo con injerto sintético, estabilización con fijador externo y cobertura con colgajo fasciocutáneo, obteniendo una evolución clínica mediante la escala de DASH con un score de 14.2 y Michigan Hand score de 70 puntos con un seguimiento de 12 meses. Conclusiones: El tratamiento con fijación externa más artrodesis del carpo con injerto sintético y cobertura cutánea con colgajo proporcionó un resultado funcional bueno para un paciente con lesión por proyectil de arma de fuego.

Background: The incidence of hand gunshot wounds in civil patients has increased in recent years; it causes long-term or permanent disability and has a personal, social and economic impact. Severe hand injuries include: involvement of the greater palmar arch, fracture of two or more carpal bones, irreducible palmar dislocations, articular fractures of the distal radius, and neurovascular injuries. All of these injuries require multiple surgical procedures for the management of soft and musculoskeletal tissues. Methods: We report the case of a patient with a Gustilo and Anderson grade IIIB open fracture of the right carpal bones caused by a gunshot projectile. He was treated with arthrodesis of the carpus using a synthetic graft, external fixation and rotation of a fasciocutaneous flap. Results: The patient underwent surgical treatment of the carpal injury that consisted of Gustilo and Anderson grade IIIB open fracture of all carpal bones caused by a gunshot projectile. Surgery included arthrodesis of the carpus with a synthetic graft, stabilization with an external fixator, and a fasciocutaneous graft as skin cover. The clinical course according to the DASH scale had a score of 14.2 and the Michigan Hand score was 70, with a 12-month follow-up. Conclusions: Treatment with external fixation plus arthrodesis of the carpus with a synthetic graft and skin cover using a flap provided a good functional result in a patient who sustained a gunshot wound.

Traumatismo accidental con estallido del globo ocular / Accidental trauma with eyeball popping-up

Paciente masculino de 27 años de edad, trabajador agrícola, que fue ingresado en el Hospital Militar Central "Dr. Carlos J. Finlay" por haber sufrido una herida penetrante por arma de fuego, producida por la impulsión retrógrada del percutor al disparar una escopeta artesanal de cacería, que provocó estallido del globo ocular izquierdo, fractura de la pared externa de la órbita y heridas palpebrales. Se retiró el cuerpo extraño, se completó la evisceración del ojo izquierdo, se recolocó el fragmento fracturado de la órbita en posición anatómica, se regularizaron los tejidos blandos intra y periorbitarios, preparando la cavidad orbitaria para la colocación posterior de la prótesis; y se realizó la hemostasia, la exploración de la cavidad neoformada por el cuerpo extraño en los tejidos blandos de la región fronto-temporal y la plastia palpebral. Se logró con éxito la reconstrucción palpebral y con posterioridad, la rehabilitación con fines estéticos mediante prótesis ocular.

A 27 year-old male farmer patient was admitted to "Dr. Carlos J. Finlay" Central Military Hospital suffering a penetrating gunshot wound, caused by the retrograde hammer when shooting a handmade hunting shotgun. This injured caused his left eyeball burst, fracture of the outer wall of the orbit and eyelid injuries. Foreign matter was removed. His left eye evisceration was completed. The fractured orbit fragment was repositioned in anatomical position. Intra and periorbital soft tissues were regularized, preparing the orbital cavity for the subsequent placement of prosthesis; and hemostasis was performed, as well as exploration the newly formed cavity by foreign matter in the soft tissues of the frontal-temporal region and eyelid plasty. Eyelid reconstruction and further rehabilitation for aesthetic purposes by ocular prosthesis was successfully achieved.

Which Graft must be Preferred in Firearm Injury of the Axillary Artery.

Aims: Interposition graft technique is used mostly in firearm wounds of axillary artery, because of excessive defect of the vessel. Autologous vein has been preferred in general application, even though there is a mild size discrepancy between native artery and autologous vein. However, in many series, prosthetic graft infection risk has been reported as low. Presentation of Case: I am presenting a patient with a gunshot wound to the right upper chest. As a first choice I preferred saphenous vein which was occluded by thrombosis at the post-repair third week in spite of anticoagulant therapy and was replaced with prosthetic graft which was patent at the eight month follow-up. Discussion: Although the theoretical risk of infection of prosthetic grafts, many previous reports have demonstrated that prosthetic grafts are nearly as safe as autologous grafts and they have high long-term patency rate. Conclusion: There is no point in insisting on autologous grafts in cases of the diameter discrepancy between native artery and autologous graft, prosthetic graft may be used more frequently in axillary artery trauma, and post-repair anticoagulants may be administered in the consequences of size discrepancy between the native artery and the graft.