Soft tissue injuries of the Head and Neck

Presenter: Nduati j Mwangi Supervisor: Dr Muriithi C.

28/10/2013

Outline

Introduction. Defination/classification.Aetiology/Epidemiology.Management. Specific injuries.Complications.Future/Controversies

Introduction

• Commonly encountered in the AE/ ED• Rarely life-threatening.• Isolated or in combination.• Treatment-can be complex, significant impact

on pt's function & aesthetics.• Few studies on these injuries.• Multidisplinary issue.

Introduction

• Mechanical rltnship btn head & neck -brick attached to a flexible rod.

• soft tissue - nonspecific term ; any tissues in the neck excluding bone.

• Head -Scalp & cranial-facial injuries• STI -injuries to muscles, ligaments & tendons.• STI include abrasions, lacerations, avulsions,

punctures, bruises.

Definations/Classification

• Abrasion -skin rubbed,scruffed off (epidermis)• Laceration-Cut skin with a jagged, irregular edges. • Incision -smooth edges• Puncture -deep,narrow wounds• contussion/bruise -blood effusion into the tissues,

caused by blunt trauma• Avulsion - torn and hanging• Amputation- cutting or tearing off.

Abrasion;Skin scraped rubbed away Susceptible to infection

• jagged edges • Bleed freely (heavily )• Pain may be minimal

Avulsion:•Tearing away of tissue •Bleeding significant (deeper tissues)

• Puncture – Skin is pierced– nail, splinter, knife, – External bldg minimal;

internal can be severe

Definations/Classification

Muscles,tendons, ligaments,capsules:•Sprain- overstretched/torn ligaments•Strain-overstreched/partially torn muscle/ tendon.•Rupture- overstreching & complete tear of muscle or tendon.•Deep bruising/ hematoma-large amount of blood in muscle

Aetiology/ injury mechanisms

• Falls, assaults, sports injuries, and motor vehicle crashes (MVA)/RTAs

• Gunshots ,blasts, animal attacks, work-related injuries, industrial accidents.

• Edalia, K. B.-MVA leading cause of MF-STls (44.6%),interpersonal violence (IPV) (39.1%).

Romeo SJ, Hawley CJ, Romeo MW, Romeo JP. Facial Injuries in Sports: A Team Physician's Guide to Diagnosis and Treatment. Phys Sportsmed. Apr 2005;33(4):45-53Edalia, K. Bernard;Aetiology, occurrence and clinical Characteristics of maxillofacial soft Tissue injuries treated at a major Teaching and referal hospital in Nairobi.2010

Epidemiology • Vary greatly depending on the pt population.– degree of urbanization,– socioeconomic status – cultural background

• Nearly 10% of all ED visits.• Slips,trips, and falls- in children & elderly• Violence & MVAs -from 15 to 50 yr olds• sports-related injury-3-29% of all facial injuries

Hussain K, Wijetunge D B, Grubnic S, Jackson I T. A comprehensive analysis of craniofacial trauma. J Trauma. 1994;36:34–47.Chang L T, Tsai M C. Craniofacial injuries from slip, trip, and fall accidents of children. J Trauma. 2007;63:70–74.Hogg N J, Stewart T C, Armstrong J E, Girotti M J. Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997. J Trauma. 2000;49:425–432.

Types of soft tissue injuries• Anterior neck injuries• Lateral neck injuries• Posterior neck injuries– Cervical contussions– Strain/sprain– Nerve stress– Vertebral artery deflection– Disc disorders– S.cord injury

• Facial(cranial-facial) injuries• Neurovascular injuries.

Soft tissue neck injury

• Neck injuries not involving fractures• Indirect injury -extension or flexion injury to

spine & neck STs.• Also lat. flexion, rotational, compressive, tensile,

shearing forces do cause injury.• Injury not the product of a single force.• Ant /lat neck -no bony protection.• Partial protection- cervical muscles, mandible,

shoulder girdle.

Management

• History-– timing,– mechanism of injury,– degree of force involved,– post injury signs & symptoms eg nausea, vomitting, LOC

• Physical examination/assesment• Investigations• Specific definative management

Management

• ATLS protocals-ABCDEs of trauma care.• Recognition& Mx of life-threatening condition• Cervical spine protection –consider it present

with all significant facial traumas.• R/O facial fractures- irrespective of the degree

of soft tissue injury.(?CT scan)

Ono K, Wada K, Takahara T, Shirotani T. Indications for computed tomography in patients with mild head injury. Neurol Med Chir (Tokyo) 2007;47:291–297. discussion 297–298.

Physical examination

Complete Head and Neck Exam-thorough but focused:-•Wounds- size, depth, and status of the wound base •Eyes-perioccular injuries,vision,mobility, lid function.•Ears-pinna ,canal, Battle’s sign, pre-aricular region, parotid status

AAO-HNS,Resident Manual of Trauma to the Face, Head, and Neck First Edition ,chapter 9.

Physical examination• Nose- nasal skeleton stability, lacerations

septal fractures, hematomas,CSF leak.• Throat- stability of the palate, missing teeth,

occlusion• Neck-lacerations, puncture wounds,crepitus,

whiplash, stability, trachea position.• Scalp- Palpate hair-bearing scalp, R/O an

underlying cranial fracture.• CNS exam- consciousness, CN status,

paraesthesias, shooting pains.

Investigations

• STIs diagnosed by history &physical exam.• Plain film radiographs- cervical spine status,

limited value for craniofacial trauma • CT scan- bone, FBs in STs, vascular structures.• Angiography- ?PNI/vascular injury.• MRI- cervical strains and sprains.• Bld works- FBC,UECs,RBS,• Toxicology-alcohol,narcotics,prescription drugs.

Ono K, Wada K, Takahara T, Shirotani T. Indications for computed tomography in patients with mild head injury. Neurol Med Chir (Tokyo) 2007;47:291–297. discussion 297–298.

Definative management

Principles in Mx STIs in general:•Protection- immobilisation with splints,casts, bandaging,taping•Rest-avoids further injury.•Ice- inexpensive cryotherapy. Decreases pain, metabolism,swelling,muscle spasm.•Compression- reduces oedema,bleeding.•Elevation-gravity aids reduce oedema.•Rehabilitation.

Surgical principles

• Repair within the first 8 hours.• Wound repair- 10,delayed 10,(contamination)

– 20 intent -uncontrolled DM, chronic hypoxia • LA /Sedation /GA• Irrigation and debridement-thorough.• Wound closure/surgical techniques.• Avoid local flaps in the 10 setting.• Drains and Dressings .• Informed consent

Aveta A, Casati P. Soft tissue injuries of the face: early aesthetic reconstruction in polytrauma patients. Ann Ital Chir. 2008;79:415–417

Specific injuries• Edalia K.,Lacerations:simple - 40.2%,Multiple 29.2% .

Abrasions -20.5% ,Avulsions - 3%• Scalp injuries-– copious irrigation,FBs removed, – staples, nonabsorbable sutures,trim jagged,macerated

edges. – R/O head injury,skull fractures

• Eyebrow injuries-– no shaving,careful alignment ,subcuticular sutures.

• Eyelid injuries-– most delicate in the face. By opthalmologist.

Edalia, K. Bernard;Aetiology, occurrence and clinical Characteristics of maxillofacial soft Tissue injuries treated at a major Teaching and referal hospital in Nairobi.2010

Ear injuries• Venous congestion/hematomas -aspiration , external

compression, splints-silicone • Simple lacerations-debridement, closed in one layer,• Skin defect,perichondrium intact -skin graft. Not

intact -resect cartilage, post auricular flap repair.• Small avulsion- replant as graft within 1st 12 hrs• Large avulsions- ?pocket technique; rib cartilage

(avulsed cartilage) as lattice ; fascial coverage & skin grafting.

Steffen A, Katzbach R, Klaiber S. A comparison of ear reattachment methods: a review of 25 years since Pennington. Plast Reconstr Surg. 2006;118:1358–1364Saad Ibrahim S M, Zidan A, Madani S. Totally avulsed ear: new technique of immediate ear reconstruction. J Plast Reconstr Aesthet Surg. 2008;61(Suppl 1):S29–S36

Ear injuries• Total/near total avulsion- microsurgical replantation.• Complete destruction/avulsion- 3 choices:-

-Autologous costal cartilage with temporoparietal fascia + advanced, expanded or grafted skin.-Polyethylene framework + temporoparietal fascia flap-Prosthesis

Nose injuries

• Address any underlying osseocartilaginous injuries • In three layers-endonasal mucosa,alar cartilage,skin.• Alar rim & columellar lacerations –skin eversion to

prevent retraction and notching.• Extensive Nasal Vestibule Injuries- stenting

Nose injuries

• Septal Hematomas-evacuation• Severe Septal Mucosal Lacerations-septal splints

(silicone)• Reconstruction -local & regional flaps e.g dorsal

nasal, cheek advancement, nasolabial & paramedian forehead

• Tissue expanders, distal free flaps .

Lips

• R/o other oral cavity injuries ,fractures• Proper lip injury Mx -correct alignment of landmarks,

layered, tension-free .• Restores motor, aesthetic,& sensory fxns of the lip• 10 closure - < 30% of the lip is involved• Landmarks-white roll, Cupid's bow, and philtral

columns• Larger defects /involves other areas:-abbe, lip-switch

procedures , local advancement flaps

Cheek injuries

• 3 subunits -infraorbital, preauricular, & bucco mandibular.

• R/O-intraoral communication, parotid duct & CN 7 injury.

• 10 repair- laxity & available soft tissue.• Also local advancement, transposition, or regional

flaps .• S/FTS grafting - cervical, preauricular, and post-

auricular skin for color matching; – s/e-contractures, scarring & contour deformities

Facial nerve injuries

• Assess status by P/E at time of presentation.• Penetrating with paresis-close observation,

nerve excitability,conduction tests.• With paralysis-exploration & anastomotic

repair.• Within 72 hrs, nerve stimulator assists in

identifying distal segment• Tissue loss -interposition nerve graft Great

auricular &sural nerves

Parotid duct injuries

• Not all need repair• Performed by suturing the duct over a stent• Conservative Rx- generally well tolerated;no long-

term functional consequences• Temporary swelling expected.

Other Perioperative Care

• Antibiotic prophylaxis– Contaminated , >24 Hours Mature.– Oronasal-Involved Wounds– Ear/Nasal Cartilage Involvement– Animal Bites(controversial)– Human Bites-deeper than the epidermis

• Topical antibiotics -high concentrations at the site, moisturization, improves reepithelization.

• Tetanus Prophylaxis.

Post op mx• Aim;-to prevent infection, promote wound healing&

improve cosmesis.• Moisturization- antibiotic ointments, petroleum jelly• Daily Debridement- removes crusts.• Dressing: +/- nonadherent ,improves moisturization &

acontamination barrier.• ROS:-5–7 days, face,7-10 days neck or scalp.• Antibiotics, good nutrition.• Head Elevation, personnal hygiene• Silicone gel application-lessens Hypertrophic Scarring

and Hyperemia

Neck injuries/wounds

• Consider all penetrating,until proven otherwise• Superficial -layered closure ,platysma re-apposed.

Tension is reduced, adequate skin blood supply• Passive drains -large areas of dead space or grossly

contaminated wounds

Specific soft tissue neck trauma

• Ant. neck injury- soft-tissue damage, possible airway Obstruction.

• Lat neck -vascular & musculature damage• Post. Neck -cervical spine & cord damage.• More critical in the young :-head wgt Vs. neck

strength

Neck trauma

Anterior neck:•Direct Vascular Injuries -highest mortality and morbidity of all neck(after spinal cord)•Laryngeal, Cricothyroid, and Tracheal injuries -Airway obstruction, 2nd most common cause of death.•Hypopharyngeal and Esophageal Injuries –odyno dysphagia

Posterior neck/Cervical spine• Neck strains -common & mostly the erectors.• Cervical sprains –ant. or post. longitudinal ligament• Strain & sprain coexist almost always. • Capsular ligaments and periarticular straps -acute

hyperkinetic subluxation.• Neck sprain and disc rupture -severe pain and

muscle spasm .• Others:- stiffness, spinous process tenderness, &

restricted motion• Poorly localized/referred pain -occiput, shoulder,

between the scapulae, arm, paraesthesia.

Post-traumatic ST disorders of the posterior neck

• Trigger Points –referred pain from muscles.• Cervical Contusions - neck muscles or cervical

spinous processes• Torticollis, Neck Spasms• Supportive management mainly.

Whiplash neck injury

• Particular type of neck Soft Tissue Injury.• Follows a sudden acceleration-deceleration force,

commonly from RTAs.• Forces result in hyperextension and hyperflexion of

the neck. • Leads to sprains/strains/microfractures of vertebral

end plates.• Vertebral fractures , dislocation or subluxation,disc

herniation, spinal cord, segmental nerve roots injury.Winkelstein BA, Nightingale RW, Richardson WJ, et al. The cervical facet capsule and its role in whiplash injury: a biomechanical investigation

SYMPTOMS

• Neck pain-dull /aching , sharp stabbing (movement), back of the neck,worse the morning after.

• neck discomfort, stiffness, tension or pulling, &/or muscle spasms, restriction of neck movements.

• Headaches-radiate to temples• inter-scapular symptoms• Shoulder-arm symptoms-pain ,discomfort, numbness

paraesthesiae.

Treatment

• Rest and collar use• Passive physiotherapy modalities-ultrasound,

laser, acupuncture,• Massage/chiropractic manipulation• Active therapy- early exercise Rx• Early exercise -superior to collar .

Kjellman GV, Skargren EI, Öberg BE. A critical analysis of randomised clinical trials on neck pain and treatment efficacy. A review of the literature. Scand J Rehab Med1999;31:139–52.Schnabel M,Ferrari R,Vassiliou T,Kaluza G.Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury Emerg Med J 2004;21:306–310.

Complications

• Injury associated with life threatening conditions• Infections/sepsis• Scarring• Disfigurement• Long term physical/emotional distress• Loss of organ function eg eye(eyesight),nose, lips.• Nerve damage with associated complications.• Chronic neck pains /syndromes associated with

whiplash injury.

Future and controversies

• More studies needed.• Neck collar usage Vs active therapy.• Tendency towards exercise (active) therapy.• Use of prophylactic antibiotics/ topical

antibiotics

References Romeo SJ, Hawley CJ, Romeo MW, Romeo JP. Facial Injuries in Sports: A Team Physician's Guide to Diagnosis and Treatment. Phys Sportsmed. Apr 2005;33(4):45-53Edalia, K. Bernard;Aetiology, occurrence and clinical Characteristics of maxillofacial soft Tissue injuries treated at a major Teaching and referal hospital in Nairobi.2010Hussain K, Wijetunge D B, Grubnic S, Jackson I T. A comprehensive analysis of craniofacial trauma. J Trauma. 1994;36:34–47.Chang L T, Tsai M C. Craniofacial injuries from slip, trip, and fall accidents of children. J Trauma. 2007;63:70–74.

Hogg N J, Stewart T C, Armstrong J E, Girotti M J. Epidemiology of maxillofacial injuries at trauma hospitals in Ontario, Canada, between 1992 and 1997. J Trauma. 2000;49:425–432.Ono K, Wada K, Takahara T, Shirotani T. Indications for computed tomography in patients with mild head injury. Neurol Med Chir (Tokyo) 2007;47:291–297. discussion 297–298.AAO-HNS,Resident Manual of Trauma to the Face, Head, and Neck First Edition ,chapter 9.Aveta A, Casati P. Soft tissue injuries of the face: early aesthetic reconstruction in polytrauma patients. Ann Ital Chir. 2008;79:415–417.

Steffen A, Katzbach R, Klaiber S. A comparison of ear reattachment methods: a review of 25 years since Pennington. Plast Reconstr Surg. 2006;118:1358–1364Saad Ibrahim S M, Zidan A, Madani S. Totally avulsed ear: new technique of immediate ear reconstruction. J Plast Reconstr Aesthet Surg. 2008;61(Suppl 1):S29–S36

Kjellman GV, Skargren EI, Öberg BE. A critical analysis of randomised clinical trials on neck pain and treatment efficacy. A review of the literature. Scand J Rehab Med1999;31:139–52.Schnabel M,Ferrari R,Vassiliou T,Kaluza G.Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury Emerg Med J 2004;21:306–310.Winkelstein BA, Nightingale RW, Richardson WJ, et al. The cervical facet capsule and its role in whiplash injury: a biomechanical investigation

Kjellman GV, Skargren EI, Öberg BE. A critical analysis of randomised clinical trials on neck pain and treatment efficacy. A review of the literature. Scand J Rehab Med1999;31:139–52.Schnabel M,Ferrari R,Vassiliou T,Kaluza G.Randomised, controlled outcome study of active mobilisation compared with collar therapy for whiplash injury Emerg Med J 2004;21:306–310.

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