In Canada, the all terrain vehicle (ATV) industry accounts for a $3.3 billion revenue and involves 975,000 operating ATVs. Over one quarter of these funds are accounted for by the purchase of new ATVs. If sales continue to grow at the current level, the ATV industry in Canada is predicting a 5.86% annual increase through 2010.1 An all terrain vehicle (ATV) is described as an “off-road vehicle” (ORV) which is propelled or driven otherwise than by muscular power or wind and is designed to travel on (a) not more than three wheels, or (b) more than three wheels and being of a prescribed class of vehicle.2
To operate an ATV in the province of Ontario, riders are required by law to wear a motorcycle helmet, have a valid driver’s licence, insurance and registration with a valid permit except in exempt areas (e.g., Far Northern Ontario).3
Residents of Ontario spend $200.6 million hunting wildlife per annum.4 Of the total expenditures approximately, $46.5 million (23.2 percent) are spent on transportation including ATV sales and service. The average hunter spends $639 during the year, or $37 per day of participation. As the population ages, there is an increasing role of ATVs in the labour intensive transportation of big-game from the field to the camp or to an access road or highway transportation.5 Large game hunting in Ontario includes moose, bear and deer. On average an adult moose stands five to six feet high and can weigh up to 1,180 lbs.6
There have been a number of case reports from the US regarding firearm related hunting accidents and craniofacial injuries.7,8 Fortunately, the “Hunter Orange” law requiring sportsmen to wear an article of bright orange clothing while hunting has led to a reduction in the incidence hunting related fatalities because they were “mistaken for game.”9
The nature and growth of ATV use has lead to a subsequent increase in the number of injuries sustained in ATV related accidents throughout North America.10,11 Although multiple system injuries are usually anticipated, head and maxillofacial injuries are very common findings after ATV accidents.12 ATV related trauma patients with maxillofacial fractures are more likely to experience neurological impairment on admission and longer hospitalizations than patients than those from motorcycle injuries.13 Pediatric trauma centers have reported fatalities related to nearly 40% of ATV crash victims, many of which result from head and neck injuries.14,15
A recent report from the University of Western Ontario provided similar statistics for children in Southwestern Ontario.16 These results clearly support the Canadian Paediatric Society’s recommendation that children under 16 years of age should be prohibited from operating or riding on ATVs.
The purpose of this article is to report a unique case of maxillofacial injuries resulting from a hunting related ATV accident and a subsequent hunting related firearms accident two months after the initial insult in the same patient.
CASE REPORT
On October 9, 2006, an otherwise healthy 38-year old male presented to the Thunder Bay Regional Health Sciences Centre emergency room for treatment and management of injuries suffered as the result of an ATV rollover accident while hunting for large game. Upon arrival the patient was ambulating, fully conscious, with full mobility of all extremities and a Glasgow coma scale level of 15. Clinical and radiographic examinations (Fig. 1) revealed extensive right sided and midfacial fractures as well as a comminuted intra-articular fracture of the left distal radialis.
A small amount of pneumocephalus was noted anteriorly, with no evidence of intracranial hemorrhage. No cervical spine infractions or dislocations were identified. The facial injuries included a comminuted fracture of the right supraorbital rim, with involvement of the right frontal sinus, which was the likely source of pneumocephalus. There were comminuted fractures of the right zygoma and zygomatic arch in addition to bilateral nasal fractures with deviation of the bony nasal septum. Fractures of the right medial and inferior orbital walls were evident. There was a prominent depression of the right orbital floor fracture with resultant displacement of the extraocular muscles and herniation of the orbital fat tissue. Both pterygoid palates were fractured and displaced medially.
Ophthalmology consultation established a decreased visual acuity associated with the right eye as the result of a significant right ocular penetrating injury a number of years previously. On examination, the best corrected visual acuity of 20/200 with marked diplopia on down-gaze was noted in the right eye and 20/20 in the left. There was no afferent papillary defect or globe rupture. A right upper lid laceration with significant ptosis secondary to edema was also noted.
The patient was further evaluated by an oral and maxillofacial surgeon and it was recommended to transfer the patient to a larger centre closer to his home and family in Toronto. Prior to transfer, the facial injuries were stabilized and he had his left distal radial forearm fracture reduced with internal fixation by orthopedics.
On October 13, 2006, the patient was transferred to a larger southern Ontario treatment facility (Mount Sinai Hospital, Toronto) under the primary care of one of Oral and Maxillofacial Surgery Training Program staff members.
After thorough clinical and radiographic examination, and appropriate orthopedic and ophthalmology re-assessment, a surgical treatment plan was devised and the patient was scheduled for to the OR for urgent surgery. A final dignosis was of upper and mid-facial fractures consisting of: a right nasal bone, a left maxillary Lefort I, and right maxillary Lefort II level fractures, a comminuted zygomatico-maxillary-orbital-complex (ZMOC) fracture, and comminuted right supraorbital rim and zygomatic arch fractures was made.
The patient was taken to the operating room and general anesthetic administered via an awake fibreoptic-assisted oroendotracheal tube which was then converted to submental intubation.17,18 A tarsorrhaphy was completed bilaterally to protect the eyes.
After the placement of Erich arch bars the fractures were exposed by using a coronal incision with a right sided preauricular extension, a right lower lid incision and an intra-oral vestibular incision extending from tooth # 16 to the opposite #26.
The entire extent of the fractures were identified, mobilized and debrided thoroughly (Fig. 2).
After the mobilization of the maxillary level fracture with Rowe disimpaction forceps the patient was placed in temporary intermaxillary fixation to re-establish the occlusion. The fractures were then fixated starting with the supraorbital fractures and nose then the right arch and ZMOC and finally the maxillary LeFort level fractures using several rigid fixtion plates (Fig. 3). The right orbital floor was explored with appropriate release of entrapped inferior rectus and orbital fat herniations. The IMF was released with a reproducible occlusion.
The incisions were closed appropriately followed by a closed reduction of the nasal septum and and placement of an external nasal splint. The submental intubation was reversed to an oroendotracheal intubation, the patient was extubated and transferred to recovery and then the ward for further monitoring by our service prior to discharge (Fig. 4).
On December 28, 2006 the same gentleman presented to the emergency room following a hunting related firearms accident. The patient was hunting small game (rabbit) when the firearm discharged accidentally. The patient presented with bilateral cheek entry wounds and no evidence of exit wounds (Fig. 5). There was substantial pain, trismus and edema localized to the buccal regions. The patient denied loss of consciousness and had no further visual disturbances. The patient continued to suffer right diplopia on down gaze, as a result of the previous trauma. Further consultation with opthomology was arranged
regarding persistent diplopia.
After appropriate clinical examination, conventional radiographic and CT imaging (Fig. 6), the patient was diagnosed with bilateral projectile bodies, the size of a 12 gauge shot, embedded bilateraly, in his infratemporal fossae. The first shot pellet came to rest inferior to right lateral pterygoid plate adjacent to the temporalis muscle. There was no intimate association with any surrounding vascular structures. The second pellet was located between the lateral and medial pterygoid muscles, just anterior to the styloid process. Although there was a vessel coursing just superior to this, there was no intimate association.
The patient was admitted for monitoring and consideration of surgical options after an appropriate course of antibiotics over the next 48 hours. Due to the nature of the injury and the patients’ desires, management consisted of non-surgical intervention with continued follow-up at regular intervals. The patient’s stay in hospital was uneventful and on December 31, 2006, the patient was discharged. The patient is still being seen in follow up by the oral and maxillofacial surgery, opthomology and orthopedics at regular intervals. The patient was advised to consider alternate hobbies, as hunting seems to have caused considerable morbidity within the last four months for this gentleman.
DISCUSSION
We presented a patient whose case delineates the extensive complexity of facial injuries that can be realized during ATV accidents. The combination of good inter-hospital relations and good inter-disciplinary cooperation achieved a timely and acceptable surgical result for this patient. Following his admission to the emergency room the nature and extent of his injuries were rapidly diagnosed and his condition was stabilized.
The multi-disciplinary team, including ophthalmology, oral and maxillofacial, and orthopedic surgeons, at both the northern and southern Ontario treatment centers coordinated ther efforts to achieve the most acceptable plan and treatment with regards to patient care and familial requests. The exposure of all bony fractures, reduction and fixation by internal rigid fixation, illustrates the preferred operative approach, based on the technical advances in trauma treatment.19 This patient’s treatment encompassed most, if not all, of the concepts of maxillofacial trauma.
The development of surgical facial degloving procedures to facilitate the more extensive exposure of fractured bones allows for ease of reduction with minimal facial scarring.20 The concept of monocortical semi-rigid and bicortical rigid plates for accurate internal fixation of bony segments allowing for decreased surgical site morbidity and healing times.21 Utilizing these concepts, we were able to accurately reconstruct the patient’s facial anatomy to an acceptable aesthetic and functional result.
Two months after the initial trauma, the patient presented back to the emergency room with a non-debilitating hunting related firearm injury. The decision to treat the patient non-surgically was made on the merit that there was no vital structure involvement associated with the injury. The patient was followed up at regular intervals to assess for risk of infection or foreign body reaction. The foreign bodies remain benign at six months post trauma.
Head and maxillofacial injuries, particularly midface injuries are common finding in ATV accidents. The oral and maxillofacial surgeon should be alerted to the frequency and pattern of facial soft and hard tissue trauma in such cases. Evidence of orbital involvement warrants opthomology consultation and involvement in the patients overall management. Accurate diagnosis and cognizant examination may warrant other consultations such as orthopedics in the previously mentioned case report.
In summary, we present a complex and extensive facial injury which required multi-center and disciplinary cooperation for treatment. The links of communication served as an ideal mode for continuity and excellence in trauma patient care.
Craig Humber is Resident in Oral and Maxillofacial Surgery and Anesthesia, University of Toronto, Canada.
Howard Holmes is Assistant Head, Division of Oral and Maxillofacial Surgery, Director of Surgical Orthodontics, Director of Undergraduate Education in Oral and Maxillofacial Surgery, University of Toronto, Canada.
Bruce Pynn is Oral and Maxillofacial Surgeon, Thunder Bay, Canada.
George Sndor is Director of Graduate Program in Oral and Maxillofacial Surgery and Anesthesia; Professor, University of Toronto; Coordinator, Pediatric Oral and Maxillofacial Surgery, The Hospital for Sick Children and Bloorview Kid’s Rehab, Toronto, Canada; Dosent, University of Oulu, Oulu, Finland.
Oral Health welcomes this orginal article.
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