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Reconstruction of head injuries
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Summary
Protection of vital structure and primary or delayed closure repair are needed in case of head injuries. If most of these wounds are easily managed with a good functional and esthetical prognosis, it can also be very challenging. To be successful the equine practitioner should be aware of various factors. Under a head wound, meticulous exploration of nerves, sinuses, cranium and nasal cavities is obligatory to ensure that nothing is missed. Tips for commonly encountered injuries affecting the lips, the tongue, the ears, salivary duct, bone structures and various head injuries are discussed.
Introduction
The head is highly vascularized, providing nutrition, oxygen, and cells for a good healing. It is one of the major reason why head wounds generally heal better than wounds of the extremities. Precise general assessment of head wounds is mandatory to decide which treatment option is appropriate. In selected cases, radiographs and ultrasonography are basic diagnostic aids for evaluating the extend of bone trauma. MRI and computed tomography, if available, also brings excellent information. (Figure 1)
Figure 1: Radiological examination of the head, (a) to diagnose the extend of a fracture; (b) to assess presence of bone sequestration; (c) CT scan.
Healing by contraction is very poor in the head region and epithelial scars can be large and non-esthetic. Therefore, primary or delayed closure should be performed as much as possible. Preoperative management should include verification that the horse is vaccinate against tetanus, administration of antimicrobial and nonsteroidal anti-inflammatory therapy. In most cases, the patient is then sedated before wound preparation and complete physical exploration. In all cases, for a better outcome, prompt and precise surgical intervention is needed, respecting the following steps: wound preparation debridement, removal of foreign bodies and loose bone fragments devoid of periosteal coverage, stabilizing the others, wound closure and dressing. (Figure 2)
Figure 2: (a) skull trauma involving left frontal sinus; (b) the wound is slightly increased to allow good debridement and lavage; (c) primary closure is started to cover bone defect; (d) wound dressing and bandage.
Tips for particular wounds
- In case of mandibular laceration, salivary gland involvement is sometimes hard to diagnose but can be confirmed by feeding the horse and observing salivary fluid loss.
- Acute head scalping and degloving injuries are generally minimally contaminated and often easily sutured on a standing sedated horse. Primary closure should be performed if possible, using rotational skin flap if necessary. If tension arising from closure is excessive, the skin is undermined with curved scissors. When multiple tissue layers are involved in the laceration, repaired is performed with as much layers of sutures needed to get a successful closure and reduce the chance of incisional dehiscence.
- Repair of nostril laceration should be made to prevent stenosis of the region.
- A lacerated ear, if untreated, may curl or flop and may end by amputation. (Figure 3)
- Eyelid laceration should be closed primarily to reduce functional problems.
- Laceration to the lips and the tongue are ideally treated by primary or delayed primary closure, but dehiscence is common if the technique of repair is poor. Superficial tongue laceration does not require suturing but the others often needs multiple layers of suture with tension suture pattern on the dorsum aspect. Amputation is sometimes mandatory and does not impair function if rostral to the frenulum.
- A lacerated salivary duct may be treated by primary closure, delayed primary closure or second–intention healing. Closure can be facilitated by suturing the duct defect over an intraluminal catheter. An alternative method is to eliminate the source of saliva by ligating the duct or chemically ablating the gland.
- In case of facial nerve laceration, motor function will not be restored and permanent sagging of the lower lip and collapse of the ipsilateral nostril will be observed. A wedge resection of the lower lip will help to restore a buccal seal.
Fractures
Trauma to the head often results in fractures of the maxilla, the mandible or the incisive bone. Most cases can be managed in the standing, sedated horse with regional anesthesia (mental or infraorbital nerves). After fracture line debridement, cleaning and manual reduction, intraoral wiring for 6 to 8 weeks is often a successful method (Figure 4).
Figure 4: (a) fracture of the rostral mandible; (b)minimum two 1.25-mm stainless steel wire are placed in two opposite directions to achieve alignment and stability; (b) mucosal ulceration is prevented by a protection apposed on each knot.
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