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Table of Contents   
CASE REPORT  
Year : 2021  |  Volume : 32  |  Issue : 2  |  Page : 268-271
Comminuted middle third orbito-zygomatic complex fracture leading to blindness due to unanticipated tyre rim explosion during service – A rare case


Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Science, Sri Balaji Vidyapeeth (Deemed to be University), Puducherry, India

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Date of Submission23-Aug-2018
Date of Decision03-Nov-2018
Date of Acceptance28-Jan-2019
Date of Web Publication26-Dec-2019
 

   Abstract 

An explosion is caused by conversion of solid, liquid into gas with resultant energy release. Blast injuries of large tyres are similar to injuries resulting from landmine explosions. Most of the patients were polytraumatised, initial evaluation and management should follow ATLS. Trauma following tyre blast results in severe soft tissue, orthopedic and head injuries. Head and face is the most commonly affected region followed by upper limb. A 40 year old male patient was watching a car tyre getting inflated with air. Unfortunately the tyre rim exploded on his face, which led to penetrating injury to the eye ball and comminuted middle third fractures. Patient was stabilized and primary hemostasis was achieved. Fractured maxilla was fixed by arch bar wiring and stabilized by using circum-suspension wiring bilaterally. Left eyeball was removed due to open globe injury and intraocular content loss. Unusual maxillofacial injuries are more common. Decision making and treatment of facial penetrating
injuries depends on number of factors, which includes location and extent of injury, type of foreign body involved, proximity of vital structures, extent of injury to soft and hard tissue and the relative benefits and risk ratio for the patient. In this case report we have explained about the primary assessment and management of blast injuries.

Keywords: Blast injury, explosion, tyre rim fracture

How to cite this article:
Sathyanarayanan R, Raghu K, Shyamala M, Nithin Joseph JB, Rajkumar R. Comminuted middle third orbito-zygomatic complex fracture leading to blindness due to unanticipated tyre rim explosion during service – A rare case. Indian J Dent Res 2021;32:268-71

How to cite this URL:
Sathyanarayanan R, Raghu K, Shyamala M, Nithin Joseph JB, Rajkumar R. Comminuted middle third orbito-zygomatic complex fracture leading to blindness due to unanticipated tyre rim explosion during service – A rare case. Indian J Dent Res [serial online] 2021 [cited 2021 Dec 8];32:268-71. Available from: https://www.ijdr.in/text.asp?2021/32/2/268/330933



   Introduction Top


Severe explosive injuries of tyres are similar to those injuries caused by landmine explosions with neither thermal or chemical effects.[1] Very minimal reports are there in literature of the destructive nature of tyre rim explosions. Injuries are fatal and cause severe deformities following tyre rim explosions, which occur during servicing by the roadside or in service stations.[2] The severity of the injury is highly dependent upon the tyre size, pressure inside the tyre and the distance between the tyre and the victim.[3] There is a wide range of injuries caused by fragments of tyre rim which includes maxillofacial injuries, long bone fractures and catastrophic head injuries. Barotraumas can cause tympanic perforation[4] and globe injuries[5] and catastrophic head injuries.[6] We report a case of communited middle third fracture leading to blindness caused by explosion of the tyre during service.


   Case Report Top


A 40-year-old male patient was watching a car tyre getting inflated with air. Unfortunately the tyre rim exploded on his face, which lead to penetrating injury to the eye ball and comminuted middle third fractures [Figure 1]. In the emergency room, suturing of the long cut wound on the maxilla was done after achieving adequate hemostasis. He was then subjected to a CT scan, which confirmed splintering of the maxilla into three pieces and fracture of the left orbital floor and lateral orbital rim and penetrating injury to the eyeball [Figure 2]. As there was no vision in the left eyeball due to open globe injury and intraocular content loss, the left eyeball was removed. The maxilla was hanging down in three pieces. It was fixed into one piece by arch bar wiring [Figure 3] and [Figure 4]. Planning on an open reduction, tracheostomy was done to maintain airway. Direct circum-suspension wiring using 26 gauge wires was performed as there were no stable points for rigid fixation. Wiring was done on the right side as the zygomatic arch was intact and in the left side it was suspended to the superior part of the lateral orbital rim through a screw drilled through the same. The maxilla was then immobilized by intermaxillary fixation to maintain occlusion [Figure 5]. Postoperatively, the fractured segment was in satisfactory alignment. An eye prosthesis was placed in the left eye in the sixteenth week [Figure 6].
Figure 1: Devastating maxillofacial and penetrating globe injury

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Figure 2: Three-dimensional Computed tomography facial bone shows comminuted fracture of middle third and zygoma-orbital complex

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Figure 3: Circum zygomatic suspension wiring

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Figure 4: Paranasal sinus view shows the circum-zygomatic suspension wiring

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Figure 5: Wound closure

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Figure 6: Frontal profile with left eye prosthesis

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   Discussion Top


Tyre blasts produce multiple injuries in the multiple bony regions that include concussion, laceration to traumatic amputation, crush syndrome to ocular injuries, death from penetrating injury. Waves reinforced and reflected at tissue density interfaces cause eye injuries. The energy of impact of these parts can be calculated from the formula:

Energy = 1/2mass × v2, where v is the velocity.

The relationship between energy and mass is linear while relationship between energy and velocity is exponential. Small particles with high velocity cause severe damage to tissues. A projectile such as piece of rim causes blunt and penetrating injury. Multiple wheel tyre assemblies are more dangerous than a single piece wheel.[3]

Suruda et al.[2] reported, tyre and wheel explosions result in fatal injuries 78% of the time and nonfatal injuries 22% of the time of nonfatal injuries.

The pressure exerted by the blast wave interacting with living tissue causes organ damage; internal organ injuries and aortic rupture are more common during tyre blast.[7] Hence thorough knowledge about the mechanism of injury, early signs and symptoms, natural courses of the blast injury will aid in the proper management of injured person.[2] So proper screening is required for proper management of blast injury victim.[6]

Blast injuries can be classified into three types, primary, secondary and tertiary. Primary injury occurs as a result of direct effect of blast wave in the atmospheric pressure. A secondary blast injury occurs when the objects accelerated by explosion energy strikes a victim, causing blunt or penetrating trauma. If the expanding gases and high wind displaces the body of the victim, it results in tertiary injury. Lacerations caused by the blast wave cause life threatening emergencies. Hence emergency physicians, surgeons and anesthesiologist must temper their interventions by delivering 100% oxygen, evaluating for tension pneumothorax and administering enough fluid to restore tissue oxygen level.[8]

Girish Kumar et al.,[9] Commandeur et al.[10] published a protocol for management of blast injuries of mandible which includes, airway maintenance, and intubation at the earliest can save life of the patient. Once airway has been established, breathing should be monitored, followed by stabilization of circulation by establishing IV lines with appropriate analgesics and antibiotics. CT scan should be done to assess the extent and severity of injury. Once CT has been obtained, emergency surgery is needed to control hemorrhage. Primary surgery involves arresting hemorrhage and suturing of mucosa to the skin. Bony apposition should be achieved to preserve soft and hard tissue during debridement. Tension band has to be applied to prevent torsion of the fragments due to muscle pull. Bony fragments attached to the periosteum may be left insitu. The remaining bony fragments act as good recipient site, at the time of secondary reconstruction. Fractured fragments can be moved and stabilized using mini-plates, micro-plates and screws. Post operatively maintenance of oral hygiene is important to prevent wound dehiscence and infection.

Similar to our case, there are few scenarios like battery explosion causing midface and mandibular injuries, which were treated with a cap splint and zygomatic suspension wiring,[11] Penetrating tyre blast injuries involving the maxilla and infratemporal fossa were treated by removal of free fragments of fractured maxillary bone after hemostasis. Balloon catheter was placed to reposition and stabilize the maxillary sinus wall, facilitate drainage and maintain an aerobic environment.[12]

Hefny et al.[3] showed that implementation of preventive methods such as increasing public awareness, inflating tyre from a distance, formal industrial safety training, tyre servicing with dedicated equipments including restraining devices, use of safety cage, complete tyre deflation during servicing and evaluation of tyre serviceability decreases the percentage of tyre blast injuries. Commandeur et al.[10] recommended that secondary and tertiary survey of blast injury victims aids in proper management.

In our case, we have completely screened the patient for external and internal injuries. Obviously there were no extensive internal injuries. Our patient had comminuted midface and zygomatico-orbital complex fracture alone with ruptured left eye ball. After obtaining an ophthalmological opinion regarding loss of vision, we eviscerated the left eye which was recommended. Maxilla was in three pieces and was floating. Intermaxillary fixation alone will not help in stabilisation of fracture and healing of fragments. Suspension wiring was therefore planned to stabilize the three fractured maxillary segments as there was no stable point for rigid fixation. The maxilla was fixed with arch bar and this arch bar was suspended to the right zygomatic arch and the left zygoma was comminuted, it was suspended to a screw fixed into the left supra orbital rim [Figure 3] and [Figure 4]. Then three layer closure done [Figure 5]. According to our plan in managing this case post operative result went well with better occlusion and facial profile. At sixth week post-operative day, the maxilla was stable with adequate mouth opening [Figure 7] and [Figure 8]. Eye prosthesis was given to the left eye at 16th week [Figure 6].
Figure 7: Frontal profile

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Figure 8: Postoperative mouth opening

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Unusual maxillofacial injuries are more common. Decision making and treatment of facial penetrating injuries depends on number of factors, which includes location and extent of injury, type of foreign body involved, proximity of vital structures, extent of injury to soft and hard tissue and the relative benefits and risk ratio for the patient.


   Conclusion Top


In this case report, we have explained about the primary assessment and management of blast injuries. Further studies would be required to explain the injury pattern and the management protocol of maxillofacial fractures caused by tyre blast injury.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Hefny AF, Eid HO, Al-Bashir M, Abu-Zidan FM. Blast injuries of large tyres: Case series. Int J Surg 2010;8:151-4.  Back to cited text no. 1
    
2.
Suruda A, Floccare D, Smith G. Injuries from tire and wheel explosions during servicing. Ann Emerg Med 1991;20:848-51.  Back to cited text no. 2
    
3.
Hefny AF, Eid HO, Abu-Zidan FM. Severe tyre blast injury during servicing. Int J Care Injured 2009:40:484-7.  Back to cited text no. 3
    
4.
Champion HR, Holcomb JB, Young LA. Injuries from explosions: Physics, biophysics, pathology, and required research focus. J Trauma 2009;66:1468-77.  Back to cited text no. 4
    
5.
Sheperd RS, Ziccardi VB, Livingston D, Lavery R. Trauma from tire and rim explosions: A retrospective analysis. J Oral Maxillofac Surg 2004;62:36-8.  Back to cited text no. 5
    
6.
Murty OP. Tyre-blast injuries. J Forensic Leg Med 2009;16:224-7.  Back to cited text no. 6
    
7.
Kumral B, Avsar A. An unusual fatal injury due to tyre blast, an autopsy case. Rom J Leg Med 2014;22:5-7.  Back to cited text no. 7
    
8.
Wightman JM, Gladish SL. Explosions and blast injuries. Ann Emerg Med 2001;37:664-78.  Back to cited text no. 8
    
9.
Girish Kumar N, Vijaya N, Jha AK. Blast injuries of mandible: A protocol for primary management. J Maxillofac Oral Surg 2012;11:191-4.  Back to cited text no. 9
    
10.
Commandeur J, Derksen RJ, Macdonald D, Breederveld R. Identical fracture patterns in combat vehicle blast injuries due to improvised explosive devices; a case series. BMC Emerg Med 2012;12:12.  Back to cited text no. 10
    
11.
Kumar V, Singh AK, Kumar P, Shenoy YR, Verma AK, Borole AJ, et al. Blast injury face: An exemplified review of management. Natl J Maxillofac Surg 2013;4:33-9.  Back to cited text no. 11
[PUBMED]  [Full text]  
12.
Malachovsky I, Janik M, Straka L. Penetrating blast injury involving maxilla to infratemporal fossa: An unusual wounding mechanism following heavy tractor wheel explosion. J Oral Maxillofac Surg Med Pathol 2016;3:239-43.  Back to cited text no. 12
    

Top
Correspondence Address:
Dr. K Raghu
Department of Oral and Maxillofacial Surgery, Indira Gandhi Institute of Dental Science, Sri Balaji Vidyapeeth (Deemed to be University), Pillayarkuppam, Cuddalore EC Road, Puducherry - 607 402
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_652_18

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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    Abstract
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