Multistage surgical management of patients with combined craniofacial injuries

Introduction. Recent observations indicate that craniofacial injuries can present as isolated, multiple, or combined trauma. Currently, there is a lack of objective criteria for determining impairments of vital functions that necessitate specialized, multidisciplinary medical care at Level I trauma centers, including multistage surgical treatment (MST) as a criterion for comprehensive management. Furthermore, criteria and indications for the comprehensive treatment of combined injuries, which account for up to 80% of cases, have not been developed in sufficient detail.

Objective. Development of a rational multistage surgical treatment (MST) protocol for combined trauma that takes into account injury severity and impaired body functions in patients with midface injuries.

Materials and methods. A total of 132 patients were examined, with males comprising 84.8% (n = 112) and females comprising 15.2% (n = 20). The age distribution of the patients was as follows: males aged 20–39 years — 44.7% (n = 59), males aged 40–59 years — 40.1% (n = 53); females aged 20–39 years — 1.5% (n = 2), females aged 40–59 years — 13.6% (n = 18). All patients were divided into three groups: Group 1 — 40 patients (30 males; 10 females) with a compensated course (trauma disease (TD) Type I); Group 2 — 44 patients (38 males; 6 females) with a subcompensated course (TD Type II); Group 3 — 48 patients (44 males; 4 females) with a decompensated course (TD Type III). The study outcomes were assessed based on injury severity and impaired body functions. Injury severity was evaluated using the Trauma Shock Potential Scale (Tsibin), the Military Field Surgery — Injury Scale (MFS-I), and the Abbreviated Injury Scale (AIS). Impaired body functions were evaluated using MFS-SE (State Upon Entry), MFS-SA (State After Admission), and MFS-SS (Specialized State) scales. Statistical data processing was performed using the Statistica 10 software package. Standard descriptive statistics were calculated (mean [M], standard deviation [SD], median [M_e], lower [Q₁] and upper [Q₃] quartiles). Hypothesis testing for the equality of means was assessed using Student’s t-test.

Results. The conducted analysis of statistical data on the nature of injuries and impaired vital body functions allowed an MST methodology to be developed. Its application enabled adequate administration of specialized resuscitative care in 90% of cases, as well as multidisciplinary surgical care. For Group 1 patients, MST was primarily provided on an abbreviated basis, without performing a tracheostomy or gastrostomy, followed by a full-scale surgical intervention during the first period of TD. Treatment for patients in Groups 2 and 3 was initiated in a shock room or an intensive care unit (ICU).

Conclusions. In cases of TD Type I, i.e., isolated maxillofacial injury with a compensated course, the principles and algorithms of the general therapeutic and tactical approach to TD management are not applicable, and the full scope of surgical interventions can be performed during the first period of TD. In cases of TD Types II and III, the full scope of MST should be implemented.

1. Gumanenko YeK, Zavrazhnov AA, Suprun AYu, Khromov AA. Severe combined trauma and polytrauma: definition, classification, clinical characteristics, treatment outcomes. Polytrauma. 2021;4:6–17 (In Russ.). https://doi.org/10.24412/1819-1495-2021-4-6-17

2. Kharitonov DYu, Dmitriev VV, Stepanov IV, Podoprigora AV, Moiseeva VS, Garshina MA. Dependence of the severity of brain damage on the localization of facial fractures in patients with combined craniofacial injuries. Journal of New Medical Technologies. 2019;26(1):22–5 (In Russ.).

3. Fokas NN, Levenetc AA, Gorbach NA, Pavlushkin AA, Metelev IA, Kravtsova GN. Research methodology traumatic injuries maxillofacial (for example Krasnoyarsk Region). International Journal of Applied and Fundamental Research. 2015;10–5:826–9 (In Russ.). EDN: ULVDCR

4. Maslyakov VV, Barachevsky YuE, Pavlova ON, Proshin AG, Polikarpov DN, Pimenov AV, et al. Analysis of the results of treatment of combined and isolated injuries of the facial skull resulting from traffic accidents in regional trauma centers. Polytrauma. 2021;4:28–38 (In Russ.). https://doi.org/10.24412/1819-1495-2021-4-28-37

5. Belen’kiy IG, Manukovskii VA, Tulupov AN, Demko AE, Kandyba DV, Sergeev GD, et al. Strategies of Osteosynthesis: Problems and Perspectives. Traumatology and Orthopedics of Russia. 2022;28(2):79–90 (In Russ.). https://doi.org/10.17816/2311-2905-1693

6. Grebnev GA, Sviridenko AD, Krasikov AV. Comparative characteristics of classifications of injuries of the middle zone of the face. Russian Journal of Dentistry. 2021;25(4):307–13 (In Russ). https://doi.org/10.17816/1728-2802-2021-25-4-307-313

7. Pfeifer R, Kalbas Y, Pape H-C. The concept of “Damage control” in polytrauma: what are standards in 2021? Polytrauma. 2021;2:10–8 (In Russ.). https://doi.org/10.24412/1819-1495-2021-2-10-18

8. Pfeifer R, Kalbas Y, Coimbra R, Leenen L, Komadina R, Hildebrand F, et al. Indications and interventions of damage control orthopedic surgeries: an expert opinion survey. European Journal of Trauma Emergency Surgery. 2020;47:2081–92. https://doi.org/10.1007/s00068-020-01386-1

9. Abu-Zidan FM, Jawas A, Idris K, Cevik AA. Surgical and Critical Care Management of Earthquake Musculoskeletal Injuries and Crush Syndrome: A Collective Review. Turkish Journal of Emergency Medicine. 2024;24(2):67–79. https://doi.org/10.4103/tjem.tjem_11_24

10. Arnaouti MKC, Cahill G, Baird MD, Mangurat L, Harris R, Edme LPP, et al. Medical Disaster Response: A Critical Analysis of the 2010 Haiti Earthquake. Frontiers in Public Health. 2022;1(10):9955–95. https://doi.org/10.3389/fpubh.2022.995595

11. Tribble DR, Murray CK, Lloyd BA, Ganesan A, Mende K, Blyth DM, et al. After the Battlefield: Infectious Complications among Wounded Warriors in the Trauma Infectious Disease Outcomes Study. Military Medicine. 2019;184:18–25. https://doi.org/10.1093/milmed/usz027

12. Stewart L, Li P, Blyth DM, Campbell WR, Petfield JL, Krauss M, et al. Antibiotic practice patterns for extremity wound infections among blast-injured subjects. Military Medicine. 2020;185:628–36. https://doi.org/10.1093/milmed/usz211

13. McDonald J, Liang SY, Li P, Stewart L, Tribble DR. DoD-VA trauma infection research collaboration. Military Medicine. 2022;187:17–24. https://doi.org/1010.1093/milmed/usab508

14. Trajano AD, Pereira BM, Fraga GP. Epidemiology of in-hospital trauma deaths in a Brazilian university hospital. BMC Emergency Medicine. 2014;14:22. https://doi.org/10.1186/1471-227X-14-22

15. Roberts DJ, Bobrovitz N, Zygun DA, Kirkpatrick AW, Ball CG, Faris PD, et al. Evidence for use of damage control surgery and damage control interventions in civilian trauma patients: a systematic review. World Journal of Emergency Surgery. 2021;16(1):10. https://doi.org/10.1186/s13017-021-00352-5