Tasks for individual work during preparation to lesson.

4.1. List of basic terms, parameters, characteristic, which a student must master at preparation to lesson:

Term	Definition
1. Fracture.	This is disorder of integrity of bone.
2. Redressation.	Reposition.

4.2. Theoretical questions to lesson: 1.1. General description of bullet wounds. 1.2. Classification of bullet damages of nasal bones. 1.3. Clinical signs of the bullet damages of nasal bones. 1.4. Basic methods of diagnostics of the bullet damages of nasal bones. 1.5. Clinical signs of direct, early and late complications of the bullet damages of nasal bones.

4.3. Practical works (task) which are executed on lesson: 1. To conduct questioning of patient and fill a hospital chart. 2. To prepare the set of tools for the inspection of injured person with the nasal bones fracture. 3. To create the diagram of inspection, to prove a diagnosis and work out a plan of treatment of injured person with the nasal bones fracture. 4. To execute the local anaesthetizing, necessary for providing a help for injured person with the bullet wound of nose.

5. TABLE OF CONTENTS OF THEME:

       Gunshot wounds require careful attention and evaluation for associated facial fractures. Both entry and exit wounds should be evaluated. Exit wounds often produce marked tissue destruction and require acute débridement. Regional flaps can be useful in treating facial soft tissue defects caused by gunshot wounds. Ballistic facial injuries are grouped by etiology: gunshot, shotgun, and high-energy avulsive injuries. Over the past 20 years advances in imaging and the duction of craniofacial approaches with rigid fixation have led to an evolution of treating facial injuries. The esthetic and functional results of facial injury are improved dramatically by the combination of a definitive open reduction of bone with early replacement of soft tissue into its primary position. Immediate definitive reconstructions with rigid fixation of the facial fractures and closure of the lacerations are recommended. Standard incisions often need to be modified because of the soft tissue wounds.

       The nose occupies a prominent position on the face and is often injured. Injuries of the internal nose should be evaluated using a nasal speculum. The septum should be evaluated for the presence of a hematoma, which appears as a bluish elevation of the mucosa. Hematomas involving the nasal septum should be evacuated with a small incision or needle aspiration. Nasal packing or polymeric silicone nasal splints can be placed to prevent recurrence of the hematomas and are removed in 7 to 10 days. A running 4-0 chromic gut mattress suture placed in and through the septum can prevent recurrence. Untreated hematomas can lead to infection and collapse of the septum and a resultant necrosis of the cartilage, which may cause “saddle nose.”

       There is an excellent blood supply to the nose. Lacerations of the external nose should be closed with 6-0 nonabsorbable sutures. Key sutures should be placed to reapproximate anatomic landmarks to ensure proper orientation, especially around the nasal rim. Bone, cartilage, and/or skin grafts may be required to reconstruct avulsive defects of the nose. Skin grafts harvested from the periauricular regions provide excellent color and texture match. Local flaps may be required to restore missing tissue.

6. MATERIALS FOR SELF-CONTROL:

A. Tasks for self-control: 1. Anatomy and physiology of face skeleton. 2.General features of gunshot injures. 3. Classification of gunshot injures of nasal bones. 4. Basic method of examination of patient with gunshot injures of nasal bones. 5. Additional method of examination of patient with with gunshot injures of nasal bones. 6. Treatment of fracture of gunshot injures of nasal. 7. Clinical features of direct, early, late complication at gunshot injures of nasal bones.

B. Tasks for self-control: 1. A patient, 29 years old, came to the maxillofacial section of the hospital concerning of  the wound in nasal area. The surgical treatment of wound was conducted with imposition of deaf sutures. What direction of stitch lines is possible to attain an optimum cosmetic effect at in this case? (Answer: on the force lines).

2. A serviceman got a wound of the face with the splinter of shell. Objectively: in undereye area to the left and in area of bridge of the nose the lacerated wound 5×5 cm, which is connected with maxillar and nasal cavities. The left zygoma and alveolar appendix of the left upper jaw are mobile. Bite is opened and slanting. On what stage of medical evacuation the intermaxillary ligature fastening of teeth according to Aivy would be held? (Answer: at regimental aid post).

3. To regimental aid post the injured person with the tangent bullet wound of maxillofacial area and considerable defect of soft tissues of nasal area and forehead is conveyed. Arterial pressure is 95/65, man is awared, there is a hemorrhea from the wound. Define the volume of the first medical aids at regimental aid post. (Answer: stop bleeding, imposition of pressing bandage, anti-shock therapy, sparing evacuation to separate medical battalion).

C. Materials for test control. Test tasks with the single right answer (a=II): 1. The bullet wounds of nose in relation to cavities and additional sinuses of nose are divided onto: A. Combined with the damages of upper jaw. B. Combined with the damages of other bones of the face. C. Blind. D. Isolated. E. Penetrated into nose or mouth cavity. (Correct answer: A).

2. Bullet wounds of nose according to damages are divided onto: A. Through, blind, tangent, penetrable in the cavities of mouth, nose, additional sinuses. B. Bruises, crushed, stabbed, cut, chopped, bitten. C. Wounds of the lower and upper jaw, zygomatic and nasal bones, several bones of the face. D. Wounds caused by bullet, fragmentation bomb explode, mine blast, wounds caused by spherical and arrow-shaped elements. E. Isolated trauma, trauma of maxillofacial area bones, combined trauma. (Correct answer: A).

3. What are the typical signs of wound of nasal area: A. Bleeding, gaping of wound. B. Liquorrhea, gaping of wound. C. Threat of asphyxia, shock. D. Bleeding, distortion of the face, impossibility to get an ordinary gas-mask. E. False defect and considerable edema of tissues. (Correct ответ: D).

D. Educational tasks of 3th levels (atypical tasks): 1. The patient, 32 years old, complains of pain and swelling in the nose, bleeding from the nose. Symptoms appeared after the injury. What is the diagnosis in this patient? What should the doctor do? (Answer: a fracture of the nasal bones. Necessary to stop the bleeding, reposition, fixation and immobilization of bone fragments of the nose).

2. To hospital brought two wounded with gunshot injuries of the nose and zygomatic bones, one of them taken from the area of radiation injury. What victim needs the first medical aid at primary stage? (Answer: patient with combined radiation injury).