Management of maxillofacial wounds sustained by British service personnel in Afghanistan

Abstract

UK service personnel sustaining maxillofacial wounds in Afghanistan are stabilised in a field hospital prior to evacuation for definitive treatment at the Royal Centre for Defence Medicine (RCDM). Descriptive injury data were gathered from the Joint Theatre Trauma Registry (JTTR) between 1 January 2008 and 31 December 2009 and matched to hospital clinical records. The mean Abbreviated Injury Severity (AIS) scores in service personnel sustaining maxillofacial wounds alone were compared with those with injuries to all body areas. Maxillofacial wounds were present in 21% of British servicemen sustaining battle injuries, but 30% of all evacuations despite the similar mean AIS of each group. This probably reflects the complex care these injuries often require that is not possible in the field. In the field hospital, maxillofacial wounds were predominantly debrided and definitive repair was deferred until evacuated to RCDM. AIS codes are an excellent predictor of mortality from face and eye wounds but they reflect morbidity poorly. The authors propose that instead of a single AIS code, each military face and eye injury should be ascribed a second separate Occulo-Facial Functional and Aesthetic (OFFA) outcome score that more accurately predicts the aesthetic and functional parameters of these wounds.

The rise in incidence of head, face and neck injuries from the twentieth to the twenty-first century is well documented . Reviews from Iraq and Afghanistan since 2003 have reported rates of head, face and neck injuries between 21% and 29% . Definitions of what constitutes a maxillofacial wound have been unclear and this has led to difficulties in comparing maxillofacial injury statistics between conflicts.

D obson et al. analysed military maxillofacial injuries between 1914 and 1986 but acknowledged that conclusive data were missing in 80% of the conflicts and used the terms ‘head and neck’ and ‘maxillofacial’ interchangeably leading to ambiguity. Current anatomical classifications used by UK and US military forces use the broad category ‘head’ to describe injuries ranging from intracranial and scalp wounds to base of skull and vault fractures. Of these, only scalp wounds are generally considered maxillofacial injuries, the remainder being traditionally considered neurosurgical. The category ‘face’ includes ophthalmic and ear injuries as well as bony facial trauma. R amasamy et al. found that the face accounted for 10% of injuries presenting to a field hospital in Iraq in 2006. They found that head wounds accounted for a further 5% but as they did not differentiate between scalp and intracranial injury it is not possible to estimate a true incidence of maxillofacial injury. Maxillofacial injuries represented 13% of British battle injuries evacuated to the UK between 2005 and 2007 . L ew et al. analysed all US cranio-maxillofacial wounds between 2001 and 2007, finding the incidence to be 26%. Careful analysis of the injury description codes used in their paper show that neck wounds were included, which does not fit into the classical British definition of a ‘maxillofacial’ wound. Table 1 shows the only papers detailing ‘maxillofacial’ injuries and excludes intracranial, ophthalmic and neck injuries. The most common cause of maxillofacial battle injuries is now from improvised explosive devices . These wounds are generally well resisted by torso body armour and helmets, leaving the face exposed.

Table 1
Papers specifically detailing maxillofacial (not intracranial, ophthalmic or neck) wounds.
Lead author Nation Conflict Dates Incidence Notes
D obson UK + US WW1 1914–1918 14% Ranging from 9 to 19%
D obson UK WW2 1939–1945 4% Not just battle injury
T inder US Vietnam 1959–1973 10–15%
J ackson UK Falklands 1982 29%
S adda Iraq Iraq–Iran war No incidence stated
B reeze UK Iraq + Afghanistan 2001–2007 13% Evacuations only
L evin Israel Lebanon 2006 2006 6% Generally gunshot
P owers US Iraq 2004–2008 No incidence stated

UK service personnel sustaining maxillofacial wounds in Afghanistan are stabilised in either the UK field hospital in Camp Bastion or the multinational field hospital in Kandahar. They are evacuated by aeroplane to the UK for definitive treatment at the Royal Centre for Defence Medicine based at University Hospitals Birmingham NHS Foundation Trust. The surgical workload of a single British field hospital in Iraq has been described but no British paper in the twenty-first century has specifically described the treatment of military maxillofacial wounds either in Afghanistan or the UK. The aim of this paper is to describe the management of maxillofacial wounds sustained by UK service personnel and to compare management between the field hospitals in Afghanistan and following evacuation to the UK.

Method

The Defence Analytical and Statistics Agency provided figures for total battle injuries sustained by UK forces and numbers of evacuations to the UK. Descriptive maxillofacial injury data was derived from the UK Joint Theatre Trauma Registry (JTTR), a restricted database very similar to that used by US forces . JTTR describes every admission generating a trauma call to a British field hospital and/or requiring evacuation back to the UK. JTTR was used to identify all neck wounds sustained by UK service personnel between 1 January 2008 and 31 August 2009. JTTR uses the Abbreviated Injury Scale (AIS), an anatomical scoring system . Every injury has an associated AIS score, ranging from 1 (mild) to 6 (severe/moribund). AIS scores are well validated in predicting severity and outcome . Coding of these injuries into JTTR is performed retrospectively in the UK by trained AIS certified nurses.

Maxillofacial injuries were defined as those affecting the facial skin, scalp and the bony facial skeleton. Neck wounds were not included. AIS scores were compared between servicemen with maxillofacial injuries versus those with injuries to other parts of the body as well as between those evacuated to the UK versus those managed definitively in theatre.

Results

Maxillofacial wounds were present in 153/743 (21%) of British servicemen sustaining battle injuries but 131/433 (30%) of all evacuations ( Table 2 ). 6/153 (4%) of maxillofacial wounds required no operative treatment and a further 16/153 (10%) of maxillofacial wounds were treated definitively in the field hospital alone and did not require evacuation.

Table 2
Numbers of maxillofacial wounds managed at Roles 3 and 4 settings.
Year Total British battle injuries Total maxillofacial battle injuries Maxillofacial injuries not requiring treatment Maxillofacial injuries treated field hospital alone Total battle injuries evacuated to UK Maxillofacial injuries evacuated to UK
2008 235 54 4 4 152 46
2009 508 99 2 12 281 85
Total 743 153 6 16 433 131

The mean AIS scores for those service personnel with maxillofacial wounds alone were lower than those for servicemen with injuries to other parts of the body ( Table 3 ). The mean AIS codes in those with maxillofacial wounds who required evacuation were far lower than those with injuries to other parts of the body.

Table 3
AIS scores in UK service personnel in those evacuated for further treatment and those that did not require evacuation.
Service personnel not requiring evacuation Service personnel evacuated to the UK
Mean AIS score (all injuries) Mean AIS score (maxillofacial injuries only) Mean AIS score (all injuries) Mean AIS score (maxillofacial injuries only)
2.1 1.9 4.8 2.2

153 service personnel sustained 234 individual maxillofacial injuries ( Table 4 ). Facial lacerations were the most common injury (82/234, 35%). The most common facial fracture was to the mandible (43/118, 36%). Only 23/234 (10%) of all maxillofacial injuries were managed definitively in the field hospital, but this was greatly increased to (11/22, 50%) when analysing intraoral injuries alone.

Feb 7, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Management of maxillofacial wounds sustained by British service personnel in Afghanistan
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