|Year : 2018 | Volume
| Issue : 3 | Page : 356-361
A study on shotgun injuries to the craniomaxillofacial Region in a Nigerian Tertiary Health Center
EB Edetanlen, BD Saheeb
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, College of Medical Sciences, University of Benin, Benin, Edo State, Nigeria
|Date of Acceptance||03-Jan-2018|
|Date of Web Publication||09-Mar-2018|
Dr. E B Edetanlen
Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, College of Medical Sciences, University of Benin, Benin, Edo State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Short-range shotgun wounds of the craniomaxillofacial region are life-threatening and are as devastating as military rifle wounds. Aims: This study aimed to evaluate the pattern of presentation of craniomaxillofacial shotgun injuries, types of shotgun injuries, and the outcome of treatments in our environment. Setting and Design: This is a prospective observational study. Materials and Methods: This is a prospective observational study conducted from February 2006 to March 2012. All patients with shotgun wounds to the craniomaxillofacial region were included in the study by convenient sampling method. Glezer's shotgun classification scheme was used to categorize the patients into short-, intermediate-, and long-range shotgun wounds. Data collected were analyzed using SPSS version 16. Statistical Analysis Used: Descriptive statistics were used to calculate the data. Mean and standard deviation (SD) were calculated for all quantitative variables such as age. Frequency and percentages were presented for qualitative variables. Results: A total number of 28 patients were seen. Ages ranged from 19 to 64 years with a mean (±SD) of 32.7 (±11.4) years. The two most commonly used shotguns were locally made pistol (25, 42.9%) and the cut-size gun (10, 35.7%) and the least commonly used was Dane gun (1, 3.6%). Close-range injury to the face was 17 (60.7%) while that of intermediate- and long-range injuries were 6 (21.1%) and 5 (17.9%), respectively. Conclusion: Wounds sustained from close-range shotguns to the face were the most common in this environment. The outcome of treatment was satisfactory when treated with conservative debridement and early reconstruction.
Keywords: Close-range wounds, craniomaxillofacial shotgun injuries, short range, shotguns, weapons
|How to cite this article:|
Edetanlen E B, Saheeb B D. A study on shotgun injuries to the craniomaxillofacial Region in a Nigerian Tertiary Health Center. Niger J Clin Pract 2018;21:356-61
|How to cite this URL:|
Edetanlen E B, Saheeb B D. A study on shotgun injuries to the craniomaxillofacial Region in a Nigerian Tertiary Health Center. Niger J Clin Pract [serial online] 2018 [cited 2020 Jul 11];21:356-61. Available from: http://www.njcponline.com/text.asp?2018/21/3/356/226965
| Introduction|| |
Shotguns, also known as scatterguns, are firearms that use energy of a fixed shell to fire a number of small spherical pellets called shot, or a solid projectile called a slug. Those mostly seen in Nigeria are locally made pistol and cut-to-size [Figure 1], single-barrel, double-barrel, and the Dane guns (muzzle loaders) while those seen commonly in developed countries are pump-, bolt-, and lever-action, semi-automatic, and even fully automatic variants. In the Western world, the majority of civilian firearm injuries are sustained from handguns (86%), followed by shotguns (8%) and rifles (5%), while shotguns are reported by some researchers to be the major cause of civilian injuries in Nigeria.,
Shotgun injuries are classified as long range (>25 cm), intermediate or shorter range (10–25 cm), and short range (<10 cm) depending on the pellets spread. Though shotguns are classified as low-velocity weapons, they can result in life-threatening and devastating wounds, similar to that caused by high-velocity weapons such as rifles if fired at a close or short range. The severity and pattern of presentation of shotgun wounds depend mainly on the effective weapon–victim range. Most authors argue that wounds from shotguns fired at a close range are similar and are as severe as high-velocity weapons and that they should be treated as such with radical debridement, drainage, and delayed reconstruction.,
|Figure 1: Cut-to-size single-barrel gun. The cut is made on the butt and the barrel|
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Timing and sequence of different stages in the management of facial shotgun wounds with reconstruction and rehabilitation are of prime importance for successful esthetic and functional outcome, which if inadequate may lead to graft rejection and frequent infection and as such multiple revisional operations may be necessary. Timing of reconstruction of gunshot wound defects is classified as early (within 10 days), delayed early (10–60 days), and delayed (more than 60 days). Specific problems are encountered in the treatment of shotgun wounds as distinguished from “gunshot wounds.”
Although little has been specifically written on the pattern of shotgun injuries in general, there is a dearth of report about the pattern of maxillofacial and craniomaxillofacial shotgun wounds as entities in contradistinction to other forms of craniomaxillofacial gunshot injuries. However, there are few reported cases of the pattern of shotgun injuries of the face that are documented in the English literature,,,, which excludes the pattern of craniomaxillofacial shotgun injuries in Africa.
Prompted by the foregoing observations, the authors decided to study the usual pattern of presentation of craniomaxillofacial shotgun injuries, types of shotgun injuries, and the outcome of treatments in our environment.
| Materials and Methods|| |
This was a prospective observational study. The study design was reviewed and approved by the Ethics Committee of our hospital with protocol number ADM/E22/VOL. V11/162. The guidelines of Helsinki declaration were followed in the present study. The study was carried out at the University of Benin teaching hospital, Benin city, Southern Nigeria, from February 2006 to March 2012. Patients with gunshot wounds to the craniomaxillofacial region from shotguns were included in the study by convenient sampling method [Figure 2]. Those excluded were the patients with gunshot wounds from other firearms which were not shotguns. Those also excluded were those who died shortly after admission, either from delay in institution of treatment or before possible benefit from therapy could have been achieved for proper evaluation of treatment. The patients were given initial lifesaving treatments to normalize the vital signs. Patients were given broad-spectrum antimicrobial therapy, which was modified when on receiving antibiotic sensitivity test reports. The face was identified to be from the vertex to the chin inferiorly and the area anterior to the tragus. The missile entry site was further subdivided into three subsites of upper face (frontal bone), mid-face (maxilla, nasal and zygomatic bone), and lower face (mandible).,
Patients' sociodemographic data, etiology, type of shotgun, range of shot, site of injury, pattern of injury, concomitant injury, time of admission, time of treatment, lifesaving treatment given, definitive treatment given, time of follow-up, outcome of treatment, and complications were recorded.
Sherman and Parry's classification scheme categorized the range of shots from guns into “point blank” or contact (0–2 m), short range or close range (2–5 m), intermediate range (5–12 m), and long range (>12 m) based on the distance of target from the weapon. This scheme could not be applied here because patients' information was subjective and therefore unreliable. However, a modification of this classification scheme devised and validated by Glezer et al. was used. This involves the use of the degree of pellets spread to determine the range of shot. This entails the use of a plain radiograph, a ruler to measure the two most distant penetration spots from the site of injury, and the mean from both values was recorded. Distance >25 cm was considered long range while the distance between 10 and 25 cm was considered intermediate range, and when the distance was <10 cm, it was considered close range.
Data collected were analyzed using SPSS version 16 (SPSS Inc, Chicago, USA). Descriptive statistics were used to calculate the data. Mean and standard deviation (SD) were calculated for all quantitative variables such as age. Frequency and percentages were presented for qualitative variables.
| Results|| |
A total of 28 patients who sustained shotgun wounds to the craniomaxillofacial region were seen during the study period. Twenty-four (85.7%) were males while four (14.3%) were females, representing an approximate ratio of 6:1. Ages ranged from 19 to 64 years with a mean (±SD) of 32.7 (±11.4) years.
Assaults from armed robbery attack (n = 15, 82.1%) were the major cause of injury and this was closely followed by assaults from cultism (8, 28.6%). Other causes were accidental discharge (n = 3, 10.7%) and unknown (n = 2, 7.1%). As shown in [Table 1], locally made pistol was the shotgun commonly used while the second commonly used was cut-to-size shotguns.
|Table 1: Distribution of type of shotgun according to the site of injury|
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The mandible was the site of injury in 18 (64.3%) patients while the mid-face was involved in 10 (35.7%) individuals. Out of the 28 patients, 17 (60.7%) of them were shot at a close range while 7 (25.0%) and 4 (14.3%) were shot at intermediate range and long range, respectively.
Twenty-six (92.9%) gunshot wound patients presented earlier than 24 h, while 2 (7.1%) presented later than 24 h postinjury. Twenty-four (85.7%) patients had treatment within 10 days of sustaining shotgun wounds and only 4 (14.3%) received their treatment after 60 days postinjury.
The pattern of presentation of shotgun wound in the face is shown in [Table 2]. There were concomitant injuries to the globe of the eyes (n = 3, 60.0%), parotid gland (n = 1, 20.0%), and the facial nerve (n = 1, 20.0%). Various modes of treatment were employed as shown in [Table 3]. The average postoperative follow-up period of the patients was 9 months for any residual deformities.
|Table 2: Distribution of pattern of injury according to the target distance|
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Out of the 28 patients, 6 (21.4%) patients suffered complications while 22 (78.6%) of the patients did not have any complications following management. The complications include loss of vision (n = 2, 7.1%), contracture (n = 2, 7.1%), parotid fistula (n = 1, 3.6%), and facial paralysis (n = 1, 3.6%).
| Discussion|| |
Shotguns are popular worldwide, and most of these weapons are more common than the rifled types. This study shows that shotguns were responsible for 100% of facial gunshot wounds sustained by victims during the period of study. This differs from studies in the Western world that reported significantly increasing cases of handgun injuries. The reason for this difference may be due to the handling of handguns, which is strictly regulated unlike shotguns. The pattern of age and sex is in consonance with earlier reports, which showed male predominance.,, This is expected as women tend to avoid violence and handling of guns and they are often treated compassionately.
This study shows that the most common cause of shotgun wound to the face is assaults. Most of the assaults were from armed robbery attack followed closely by cultism. Though there were rare cases of accidental discharge by a hunter and a local vigilante officer, there was no single case of suicide associated with shotguns. This agrees with the findings of Obiechina and Fasola who also conducted their study in urban settings but differ from those of Ugboko et al., who reported accidental discharge as the most common cause though their study was conducted in a rural setting. The reason could be that rural dwellers lack the training skills in handling firearms. This finding also differs from most studies reported in the Western literature, where suicide was the major cause., Amole et al. reported the most common cause of shotgun injuries to be regional conflict in the northern part of Nigeria.
Interestingly, all the shotguns that inflicted the facial injuries were locally made. The most common mortality was inflicted by locally made pistol and this was closely followed by cut-to-size locally made shotguns. This lends support to other studies in Africa,, but differs with studies from the Western world.,, The reason is that shotguns are mostly employed in game hunting in overseas, while it is mainly used for crimes in our environment because they are locally designed to be concealed. In the Western world, handguns are mainly used to commit civilian crimes since they are also concealable weapons.
The effect of distance to target is most notable in shotguns and is the principal basis for classifying shotgun injuries. This study revealed that most victims were shot at point-blank range or with the gun in contact with the skin. This differs from other studies that reported most victims being shot at intermediate or long range., This is because most victims in this study were closely monitored by the attacker whose intention was to rob while being scared of unforeseen circumstances. Long-range wounds usually resulted from accidental discharge. Though no suicidal cases were reported in this study, there are other studies that reported close-range wound from shotguns with a suicidal intent.,
Consideration of shotgun wounds as contaminated is still an area of debate. Some researchers, consider the wounds as contaminated because they are open wounds while others only consider them contaminated if presented after 24 h. Though the pellets [Figure 3] carry dirt and contaminants, they are considered sterile by the heat generated by the kinetic energy when the weapons are fired., In this study, more than 80% of victims presented earlier than 24 h. This is similar to other studies that reported the same., The reason for this earlier presentation to the hospital is obviously because most victims were shot at a close range leading to devastating and life-threatening facial wounds.
|Figure 3: Pellets/shots; these are ammunition fired by shot guns, for example, barrels|
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The lower third of the facial skeleton was more frequently injured than the middle third of the face in the present study. This finding did not differ from other studies which showed lower facial third predominance.,, It, however, contrasted with those of other authors who noted more injuries in the middle third of the face.,
Although shotguns are technically low-velocity weapons, they cause major soft-tissue, nerve, bone, vascular, and joint injuries, resulting in mortality rate nearly twice of those that are attributed to other weapons. The wounding potential of a shotgun is dependent on a bolus blast that can be reduced by pellet spreading. Unlike other weapons that can inflict a particular injury, injuries from shotguns are unique in the sense that the shotguns can inflict various degrees of injuries depending on the range of shot. The shotguns can inflict wounds ranging from penetrating wound to avulsive wound. In this study, avulsive wound was more predominant than the penetrating wound. This finding is in agreement with that of Shepard who reported similar findings. The reason for this is that at a close range, the pellets or shots strike the target as a single mass resulting in massive kinetic energy transfer, tissue avulsion, and high mortality rate. This finding was contrary to that of Goodstein et al., who reported a higher incidence of puncturing or penetrating wounds among game hunters. The reason for this greater incidence is that most of the hunters were shot at a long distance, thereby dispersing the pellets and ultimately loss of energy.
In some studies, the most common concomitant injury was trauma to the facial nerve., This, however, contrasts with our findings, but agrees with other studies,, which had injury to the globe as the most common concomitant injury. The consensus of opinion worldwide is that shotgun wounds should be treated in the context of an acute traumatic emergency. All patients presenting with severe lacerations within 24 h or above should be conservatively debrided. This contrasts with studies that recommended radical debridement in extensively lacerated gunshot wounds.,
The timing of definitive reconstruction of the defective area is an area of continuing debate.,, However, in this study, most of the reconstructions of soft- and hard-tissue defects were performed within 10 days of posttrauma. We recorded a mortality rate of 9.1%, which shows that the outcome of management of our patients could be regarded as satisfactory.
| Conclusion|| |
Craniomaxillofacial gunshot wounds sustained from shotguns fired at a close range were the most common in this environment and the conservative debridement and early reconstruction received by most of the patients gave a satisfactory outcome. Therefore, the findings in this study support the evidence of conservative debridement and early reconstruction for all injuries resulting from shotguns even when they are similar to that caused by high-velocity weapons.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We thank our colleagues and other support staff in the department for allowing us to recruit their patients and for their support and cooperation, respectively.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]