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FACIAL INJURIES BY COLD STEEL
CASE REPORT
FACIAL INJURIES BY COLD STEEL
CASE REPORT
FERIMENTOS FACIAIS POR ARMA BRANCA
RELATO DE CASO
Pedro Henrique Silva GOMES-FERREIRA *
Luiz Fernando Azambuja ALCALDE **
Norton Ryuji NARAZAKI *
Marcos Maurício CAPELARI ***
Gustavo Lopes TOLEDO ***
Clóvis MARZOLA ***
_________________________________________
* Dentist conclusive Course Residency in Surgery and Maxillofacial, Portuguese Beneficent
Hospital, Bauru, SP, Brazil.
** Dental Surgeon and Specialist in Oral and Maxillofacial Surgery Maxillofacial at Home
Course in Surgery and Maxillofacial and Brazilian College of Surgery and
Traumatology BMF, accredited by the CFO.
*** Professor, Residency in Surgery and Maxillofacial, Portuguese Beneficence, Bauru, SP,
Brazil Hospital.
GOMES-FERREIRA, P. H. S.; ALCADE, L. F. A.; NARAZAKI, N. R. et al., Facial injuries by cold steel – Case relate.
Rev. Odontologia (ATO), Bauru, SP., v. 14, n. 12, p. 711-718, dez., 2014.
712
FACIAL INJURIES BY COLD STEEL
CASE REPORT
ABSTRACT
Injuries by cold steel in the face are little reported in the national
literature. Its incidence is higher in male subjects, between 15 and 35 years
of age, with prevalence on the left hemi-face. On the initial care there is
recognition of the injuries and the implementation of measures to sustain life.
Diagnosis and classification of facial injuries are of paramount importance
allowing the treatment to be based on etiology and complexity of trauma.
The depth and extent of the injury, the need for reconstruction, injuries to
significant anatomical structures and the time elapsed since the trauma is
essential information to define the specific treatment. This work aims to
present a case of physical aggression with multiple stab wounds involving
facial and thoracic region in a male patient, 35 years of age, who was
admitted to the Emergency Municipal Center Bauru. Patient presented
depneumotórax right and left hemothorax treated by an emergency medical
team, following the protocol of ATLS (Advanced Trauma Life Support). With
the clinical condition of the patient stabilized, the team of Oral and
Maxillofacial Surgery treatment started. In analysis of computed tomography,
there was the front wall of the maxillary sinus and left hemossinus fracture, in
which conservative treatment was instituted. Anesthetic infiltration was
carried out at the edges of wounds, antisepsis with povidone degermant and
topic, debridement of the wound and suture in layers. Postoperatively 30
days, there was an acceptable esthetic condition of stab wounds in the face
when these are properly treated.
RESUMO
Ferimentos por armas brancas (FAB) na face são pouco
relatadas na literatura nacional e, sua maior incidência ocorre em indivíduos
do gênero masculino, entre 15 e 35 anos de idade, com prevalência pela
hemi-face esquerda. No atendimento inicial há o reconhecimento das lesões
e aplicação de medidas para manutenção da vida. O diagnóstico e a
classificação dos ferimentos faciais são de suma importância possibilitando
que o tratamento seja baseado na etiologia e complexidade do trauma. A
profundidade e extensão da lesão, a necessidade de reconstruções, injúrias
às estruturas anatômicas nobres e, o tempo decorrido desde o trauma são
informações essenciais para definir o tratamento específico. Este trabalho
tem como objetivo apresentar um caso de agressão física com múltiplos
ferimentos por arma branca envolvendo região facial e torácica em um
paciente do gênero masculino, 35 anos de idade, que deu entrada no Pronto
Socorro Municipal Central de Bauru. Paciente apresentou quadro de
pneumotórax direito e hemotórax esquerdo, tratado emergencialmente pela
equipe médica, seguindo o protocolo do ATLS (Advanced Trauma Life
Support). Com o quadro clínico do paciente estabilizado, a equipe de
Cirurgia e Traumatologia Bucomaxilofacial iniciou o tratamento. Em análise
de tomografia computadorizada, observou-se fratura de parede anterior do
seio maxilar e hemossinus esquerdo, sendo instituído o tratamento
conservador. Foram realizadas infiltrações anestésicas nas bordas das
feridas, antissepsia com PVPI degermante e tópico, debridamento das
feridas e sutura por planos. No pós-operatório de 30 dias, observou-se uma
GOMES-FERREIRA, P. H. S.; ALCADE, L. F. A.; NARAZAKI, N. R. et al., Facial injuries by cold steel – Case relate.
Rev. Odontologia (ATO), Bauru, SP., v. 14, n. 12, p. 711-718, dez., 2014.
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FACIAL INJURIES BY COLD STEEL
CASE REPORT
condição estética aceitável dos ferimentos por arma branca na face ao
serem tratados adequadamente.
UNITERMS: Wounds and Injuries; Wounds; Penetrating; Traumatology.
UNITERMOS:
Ferimentos
Traumatologia.
e
Lesões;
Ferimentos
Penetrantes;
INTRODUCTION
Injuries melee weapons (FAB) on the face are little reported in
the national literature and its highest incidence occurs in male subjects,
between 15 and 35 years of age, with prevalence for left hemi-face
(DIMITROULIS; EYRE, 1991; PENA; MARZOLA; CAMPOS et al., 2000;
LE; DIERKS; UEECKS et al., 2001; SHINOHARA; HERINGER;
CARVALHO JR, 2001; GASPARINI; BRUNELLI; RIVAROLI et al., 2002;
AZEVEDO; CARNEIRO JR; GONZALES, 2003; MOTAMEDI, 2003;
FRIEDRICH; SCHULZ, 2005; PENA; MARZOLA; CAMPOS et al., 2006
and MARZOLA, 2008).
This type of trauma can result in different injuries such as soft
tissue laceration, bone fracture and laceration and fracture with retained
foreign body in the region (MOTAMEDI, 2003 and FRIEDRICH; SCHULZL,
2005).
These lesions present incidence related to socioeconomic
factors (SANTOS JR, 1992; AZEVEDO et al., 2003 and MARZOLA, 2008).
Many events also influence the severity of facial injury, as the object used, its
shape and size, direction and intensity of the trauma and the affected regions
(GASPARINI; BRUNELLI; RIVAROLI et al., 2002; FRIEDRICH; SCHULZ,
2005 and MARZOLA, 2008).
For the initial treatment aimed at recognizing the lesions posing
a risk of death beyond applying measures to sustain life until definitive
treatment is started, avoiding errors that may lead to death, it is essential
(TEIXEIRA; INABA; HADJIZACHARIA et al., 2007; IVATURY; GUILFORD;
MALHOTRA et al., 2008 and MARZOLA, 2008).
Diagnosis and classification of facial injuries are of paramount
importance allowing the treatment to be based on etiology and complexity of
trauma. The depth and extent of the injury, the need for reconstruction, injury
to anatomical structures, in addition to the time elapsed since the trauma is
essential information to define the specific treatment (MARZOLA, 2008 and
CARRASCO; ZORZETTO; MARZOLA et al., 2012).
The treatment of facial injuries comprises the suture soft tissue
and possible reduction and fixation of bone fractures. Still, facial
reconstructions in case of loss of substance, respecting the principles and
techniques of each step, part of the definitive and transitional treatment
during initial evaluation of poly traumatized patient (COHEN; BOYESVARLEY, 1986 and MARZOLA, 2008).
This work aims to present a clinical case of treatment of facial
injuries by stab in the face.
GOMES-FERREIRA, P. H. S.; ALCADE, L. F. A.; NARAZAKI, N. R. et al., Facial injuries by cold steel – Case relate.
Rev. Odontologia (ATO), Bauru, SP., v. 14, n. 12, p. 711-718, dez., 2014.
714
FACIAL INJURIES BY COLD STEEL
CASE REPORT
CASE RELATE
J. M. V. patient, 31 years, male, was admitted to the Emergency
Municipal Center Bauru, SP, Brazil, victim of physical aggression with
multiple stab wounds involving the facial region (Figure 1).
Figure 1 - Facial injuries with knives.
Source: Collection of the Department of Oral and Maxillofacial Surgery Center of
Emergency Bauru.
Patient developed right pneumothorax and left hemothorax,
diagnosed with the aid of chest radiography (Figure 2) and treated by an
emergency medical team, following the protocol of ATLS (Advanced Trauma
Life Support).
Figure 2 - RX P-A-rays.
Source: Collection of the Department of Oral and Maxillofacial Surgery Center of
Emergency Bauru.
GOMES-FERREIRA, P. H. S.; ALCADE, L. F. A.; NARAZAKI, N. R. et al., Facial injuries by cold steel – Case relate.
Rev. Odontologia (ATO), Bauru, SP., v. 14, n. 12, p. 711-718, dez., 2014.
715
FACIAL INJURIES BY COLD STEEL
CASE REPORT
With the clinical picture stabilized patient, staff of Maxillofacial
Surgery started treatment of lesions on the face. In analysis of CT axial
section of the maxillary sinus region, was observed in the anterior wall of the
maxillary sinus and left hemossinus (Figure 3). Fracture, conservative
treatment is instituted.
Figure 3 - Computed tomography with opacification of the left maxillary sinus.
Source: Collection of the Department of Oral and Maxillofacial Surgery Center of
Emergency Bauru.
Regarding the cut-blunt injuries, there was no involvement of
important structures, anesthetic infiltration being held on the lips of the wound
antisepsis with povidone degermant and topic, debridement of the wound
and suture in layers using polyglactin 910 and nylon (Figure 4).
Figure 4 - Final appearance of the suture.
Source: Collection of the Department of Oral and Maxillofacial Surgery Center of
Emergency Bauru.
GOMES-FERREIRA, P. H. S.; ALCADE, L. F. A.; NARAZAKI, N. R. et al., Facial injuries by cold steel – Case relate.
Rev. Odontologia (ATO), Bauru, SP., v. 14, n. 12, p. 711-718, dez., 2014.
716
FACIAL INJURIES BY COLD STEEL
CASE REPORT
Postoperatively 30 days, we observed absence of any degree
of facial paralysis and an acceptable cosmetic condition of stab injuries due
to the correct treatment properly (Figure 5).
Figure 5 - Appearance after surgery 30 days (front view).
Source: Collection of the Department of Oral and Maxillofacial Surgery Center of
Emergency Bauru.
DISCUSSION
The patient entry into a Service Emergency Department after
being the victim of stab injuries, the initial treatment is based on steps that
must be followed, in order to correct identification of lesions and may lead to
the risk of death and subsequently have the definitive treatment performed.
For this, a multidisciplinary team led by the responsible surgeon must act
quickly, dictating the patient's needs at that moment (BERNHARD;
BECKER; NOWE et al., 2007; TEIXEIRA; INABA; HADJIZACHARIA et al.,
2007; IVATURY; GUILFORD; MALHOTRA et al., 2008 and MARZOLA,
2008). As described in this case, where diagnosing pneumothorax and
hemothorax, injuries that could lead to patients' death and were treated
appropriately aimed at the vital stability of the patient, so then to start
definitive treatment.
Not been diagnosed sensory or motor lesions that damage the
function and social life of the patient after the treatment, because his wound
was present in nerve terminal region, and away from other structures. With
all this, did not take to intervene with microsurgical procedures for nerve
repair, as well as to repair ducts of salivary glands as described in the
research literature (DAVIS; TELISCHI, 1995; ARNAUD; BATIFOL;
GOUDOT et al., 2006 and DEMIAN; CURTIS, 2008).
Hemostasis was performed unnecessary use of electrocautery
and / or bandages, only a slight manual compression was effective in
operative trans, studying without bruising postoperatively that could impair
GOMES-FERREIRA, P. H. S.; ALCADE, L. F. A.; NARAZAKI, N. R. et al., Facial injuries by cold steel – Case relate.
Rev. Odontologia (ATO), Bauru, SP., v. 14, n. 12, p. 711-718, dez., 2014.
717
FACIAL INJURIES BY COLD STEEL
CASE REPORT
wound repair. The literature indicates a low incidence of hemorrhage in
facial trauma that may put the patient at risk (ARDEKIAN; SAMET;
SHOSHANI et al., 1993; YANG; TSAI; HUNG et al., 2001; BYNOE;
KERWIN; PARKER et al., 2003; MARZOLA, 2008 and DEAN; LEDGARD;
KATSAROS et al., 2009) corroborating the case presented, given the fact
that the bleeding was minimal and did not present risks to the patient.
The management of these injuries is simple, provided that they
present excessive bleeding, bruising or compromise with rapid expansion of
regions which involve large vessels and can be done under local anesthesia
(MEER; SIDDIQI; MORKEL et al., 2009). This type of injury can injure face
structures like the parotid duct, the gland itself and the facial nerve by
penetrating and sharp character. To the facial nerve is unusual, about 5% of
all the types of traumatic injuries of the facial nerve (LI; GOLDBERG; MUNIN
et al., 2004). Seen in this case where the procedure was performed under
local anesthesia with conscious patient and subsequently had motor function
(muscles of mimicry) preserved.
CONCLUSIONS
Traumas in the face by FAB have low complication rate when
treated appropriately.
It is possible to obtain an acceptable cosmetic condition of the
FAB in the face when a suitable protocol is established.
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____________________________________
* According of the ABNT norms and of the ATO Review.
o0o
GOMES-FERREIRA, P. H. S.; ALCADE, L. F. A.; NARAZAKI, N. R. et al., Facial injuries by cold steel – Case relate.
Rev. Odontologia (ATO), Bauru, SP., v. 14, n. 12, p. 711-718, dez., 2014.