FRACTURA DE ARCO CIGOMATICO PDF

Rodenas-Lozano , J. D Molina-Nuevo , R. Paradoxical arterial gas embolism following a direct incisive injury to the skull Introduction. An arterial gas embolism is defined as the presence of air in the arterial circulation. This is an extremely rare cause of stroke that has been described in a multitude of clinical scenarios, generally related to iatrogenic processes.

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Medina A. Debora DDS, M. Correspondence to: Dr. Fabio Gregorio Arriola Pacheco - f-arriola hotmail. The surgical management of firearm injuries to the zygomaticomaxillary complex is a topic that needs to be addressed with much care. The complications that can arise during treatment, as well as the potential residual problems that can appear, lead to the need of recognizing these injuries as a maxillofacial treatment challenge.

The case presented is of a 54 year old man affected by the backward firing of a gun rifle that caused an oblique impaction towards the posterior lateral inferior side of the infraorbital complex. He was rapidly stabilized with an antibiotic and analgesic scheme, yet presented the following: a comminute fracture of the orbit floor with consequent communication towards the maxillary sinus, a non-displacing fracture of the frontomalar suture, a non-displacing fracture of the zygomatic arch and a lesion with loss of osseous tissue in the petrous region of the temporal bone.

Rigid fixation followed stabilization, and the area was covered with a titanium mesh. Occasional tinnitus and photopsia were reported by the patient upon return, yet all other evaluated factors were in order. There have been different forms of management described in the literature, and it is recognized that each patient has different needs, therefore each case must be closely evaluated, so it is approached in the most appropriate manner.

Firearm injuries represent some of the most complex and difficult challenges in maxillofacial surgery 1, 2. In the U. The infraorbital zone the facial region below the orbit and lateral to the nose on each side is the second most common area of injury in the face, only preceded by the nasal bone 7, 8.

The reasons behind these injuries are multiple and include: violent assault, unintentional injuries falls, transportation-related injuries, accidental injuries, such as in hunting , intentional injuries, forces of nature, war, and legal intervention 9, The typical management of these injuries requires primary focus on clearing and controlling the airway patency , normally with a tracheostomy, followed by hemorrhage control 2, 3, 11, Most of these procedures are then followed by hemodynamic resuscitation, evaluation of other affected areas and reconstructive surgery if needed 11, As it can be noted, the complexity of management of these injuries, as well as the concomitant results and residual effects require a careful study of the case, as well as an understanding of what procedures are appropriate for each case.

At arrival, the patient was in a conscious state, hemodynamically stable, with a non-compromised airway, but with edema in the affected zone and reporting general pain in the area. He referred loss of sensitivity of the tissues surrounding the nose, upper left lip, and lower left eyelid, leading to suspect of a direct lesion to the infraorbital nerve.

He also referred tinnitus in the left ear, impossibility to open the left eye, and photopsia when he attempted to forcefully open the afore mentioned Figure 1. The patient was initially stabilized and managed IV with a double antibiotic scheme using: 1 g. The integral evaluation of the wounds was carried out, by first cleaning the lesions with saline solution and then evaluating the tissue and structure loss.

A teleradiography and CT scan revealed that the object had an oblique impaction direction towards the posterior lateral inferior side, therefore provoking the following: a comminute fracture of the orbit floor with the consequent communication towards the maxillary sinus, a non-displacing fracture of the frontomalar suture, a non-displacing fracture of the zygomatic arch and a lesion with loss of osseous tissue in the petrous region of the temporal bone Figure 2 and 3.

Once the extension of the wound was determined, the surgical act followed. The first step consisted in removing, through traction, the impacted metallic object. In the part that was underlying inside the tissues, there was a metallic nut, which was part of the gun; with this finding it was necessary to assure it through clockwise rotatory movements, before actually performing the traction Figure 4, 5, 6.

After clearing the object from the area, it was flushed with saline solution, with the debridement of the non-salvageable tissue followed by the reduction of the orbit floor fracture. Rigid fixation was then performed, previously having taken the appropriate measurements to design and place a titanium mesh that was fixed with titanium screws Figure 7, 8, 9.

Primary closure of the wound followed, first suturing the muscular plane utilizing absorbable polyglycolide acid suture and posteriorly closing the cutaneous plane with nylon suture Figure Pharmacologically, the patient was controlled with 1 g. The patient attended a follow up, one month posterior to the accident.

During this session, the following things were evaluated: bio-acceptability of the material, appropriate wound healing, and ocular mobility degree to asses muscular and nerve damage. The patient referred having inconstant tinnitus, and occasional photopsia, that will be closely monitored. The patient presented in the case is another prime example of how a gunshot injury can represent a real challenge at the moment of trying to give an immediate and appropriate response.

The patient that attended the medical service fell in an age above years old average what is reported in different studies of firearm injuries 2,6,10,11,13— Regarding the sex, he fell in concordance of the majority of studies that mention that men have a higher prevalence of these types of injuries 3,5,6,10,11, It has been reported that regarding non intentional firearm injuries, those that happen by a rifle represent the lowest percentage, after handgun, and shotgun injuries 16 ; this gives the case a more interesting take on the rarity of these lesions.

The buttresses that make up the midface part- the nasomaxillary buttress, the pterygomaxillary, and and the lateral or zygomaticomaxillary one, are very important due to their aid in resisting blows that this area receives 7, In the majority of cases, the appropriate approach to treatment of maxillofacial trauma is via early comprehensive repair and simultaneous open reduction for maxillofacial fracture fixation Another great benefit to the treatment is restoring continuity primarily, because if this is done late, fibrosis occurs around bone segments and this creates difficulty in movement, or the tissue may even become necrotic These patients can be submitted to primary debridement and arch bar placement followed by open reduction of the fractures.

Additional to arch bars, the use of titanium miniplates are an excellent rehabilitation choice, especially in the public health setting where the patient attended There are newer technologies in the market that allow for more precise and advanced biocompatible options for restoration, such as 3D printed meshes, yet this option of treatment is still limited to a certain population that can afford the cost, as well as practioners that have access to the technology 20, On the other hand, photpsia has not been reported with high incidence of post traumatic orbital injury, but does form part of the symptoms for severe injury, along with pain, floaters, diplopia and scotomata As it can be observed, the management of wounds to the infraorbital area is as complex as its treatment.

The correct therapeutic and pharmacological approach will permit a better chance of recovery for the patient. The importance of function and aesthetic in this area leads us to promote the reporting of the management of these cases, so knowledge to the correct management can continue. Private Practice in Merida, Mexico.

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Medina A. Debora DDS, M. Correspondence to: Dr. Fabio Gregorio Arriola Pacheco - f-arriola hotmail. The surgical management of firearm injuries to the zygomaticomaxillary complex is a topic that needs to be addressed with much care. The complications that can arise during treatment, as well as the potential residual problems that can appear, lead to the need of recognizing these injuries as a maxillofacial treatment challenge.

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