UNUSUAL BEAR MAUL INJURIES - TJPRC...midface which being the most prominent part of face. The goal of the present study was to report Unusual injuries on other parts of face like mandible,

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UNUSUAL BEAR MAUL INJURIES

PARVEEN AKHTER LONE 1, TASLEEM KOUSER 2 & ASIF IQBAL 3

1Associate professor & Head deparment of oral & Maxillofacial Surgery, Indira Gandhi Government Dental College JAMMU . AFFLIATED with University of Jammu

2Consultant Radiodiagnosis J & K health Services , Affliated with University of Kashmir

3House Surgeon Department of Oral & Maillofacial Surgery indira Gandhi Government Dental College Jammu. Affliated with University of Jammu

ABSTRACT

MAUL means to injure by rough treatment, to use roughly, manhandle, spoil the appearance, handle roughly.

Bears are strong and agile wild, potentially dangerous, unpredictable animal & can cause serious injuries. Bear attaks are

reported from nearly all part of the world .Bear human interactions were rare & Injuries due to bear mauling are rarely

reported in the literature but the conflict between human & animals is increasing due to excessive greed of human with

encroachment of remote bear territory leading to diminshed bear territory .A search of scientific literature describes very

limited articles showing in depth analysis of bear maul injuries & management of maxillofacial wounds..ALL the studies

reveal involvement of face & scalp along with other body viscera but most of the studies have shown involvement of

midface which being the most prominent part of face. The goal of the present study was to report Unusual injuries on other

parts of face like mandible, & eye demage, disfiguring scars, facial nerve paralysis, contaminated mandible & midface

fracture with teeth alveolar bone& foreign bodies embedded in wounds.

KEYWORDS: Malunited Mandible Fractures, Midfacial Injuries, Bear Attack Foreign Body

INTRODUCTION

The himalayan range, surrounded by dense forests is a habitat of Asiatic Black bears (Ursus thiabetans) Bears are

strong potentially dangerous agile & has ability to defend themselves if feel threatened. Human & bear conficts are on rise

for past few years because of loss of forests especially outside the protected areas which has posed a major threat to wild

animal [1]. The degradation & loss of forests, overgrazing, tree cutting, fire, overextraction of forests resources & dry

forests is on rise decreasing bear territory thus increasing the chances of human bear encounters[2]. Such attacks result in

major human injuries as well as death. Animal bite wounds are more common on upper extremities but a large percentage

are also located on the face and head [ 3]. These injuries vary from

minor scratches to major trauma like fractures skin & deep soft tissue injuries joint demages, neurovascular

demage, visceral injuries. Bear bite wounds are often underestimated & untreated. Different animals attack in different

ways & this is useful in determining injuries. Black bear attacks are categorized in sudden, provoked & predatory. Facial

injuries caused from such injuries not only create functional problems but also facial disfigurement, psychological

problems which causes individual to avoid social contacts [4] Although Limited literature is available describing the bear

maul injuries, our aim was to report the detailed and unusual facial injuries caused by bear attack & Also to educate &

create awareness & importance of earliar referral in order to avoid disfigured scaring of face, preventing victims from

psycologic problems. This study carries significance because almost all the literature available is about fresh/primary

Journal of Dental Research and Development (JDRD) Vol. 5, Issue 1, Jun 2015, 11-22 © TJPRC Pvt. Ltd.

12 Parveen Akhter Lone, Tasleem Kouser & Asif Iqbal


injuries, residual/delayed injuries have not been reported.

MATERIALS & METHODS

The prospective study was conducted in oral & maxillofacial surgery department of indira Gandhi Govt dental

college jammu from year august 2012 to October 2013 Tthe study was conducted in 20 patients of bear maul injuries

referred to the department by various hospital for treatment of maxillofacial injuries. Out of twenty cases, five cases

reported late because in four patients injuries were un noticed during primary management ,&one patient had fatal head

injury,& was referred late for treatment

Patients who reported late with unusual presentations were slected for reporting

They had following injuries

• Sever facial scars with malunited fracture maxilla & mandible [FIGURE 1, 2 ,3]

• Disfiguring facial scar with malunited fracture maxilla .with permanent loss of vision & globe demage.

[FIGURE 4,5, 6, 7]

• Facial paralysis without involvement of parotid gland ,with thoracic & abdominal injuries [FIGURE 8, 9, 10]

• Malunited fracture maxilla with dentoalveolar fracture wihh teeth & alveolar bone embedded in buccal mucosa

[FIGURE 11 &12]

• Malunited Fracture mandible with foreign body in the wound [ FIGURE 13]

A detailed history from patients /attendents was recorded, date ,time of injury, nature & duration of attack single

bear or soy with kids, any defensive measure taken by victims, purpose of visiting forests was also enquired. The primary

treatment, tetnus & rabbies prophylaxis was noted. A detailed clinical examination from head to toe was made to evaluate

the site & type of injury, soft tissue & bony injuries. Head chest abdominal & skeletal wounds/injuries were noted down.

Routine investigations including radiography was done in all cases ,special investigations like CT scan ultrasonography

was done whenever indicated &finally statiscal analysis of all collected data was made.

CASE 1

Unusual Bear Maul Injuries 13


Figure 1: PRE OP PHOTO Disfigured Scars with Fracture Mandible

Figure 2 & 3: POST OP photograph

CASE 2



Figure 4, 5: Pre op photo

Figure 6, 7: POST OP PHOTO



CASE 3

Figure 8: PRE OP PHOTO Facial Paralysis

Figure 9: Thoracic & Abdominal Injuries

Figure 10: POST OP PHOTOGRAPH

CASE 4



Figure 11 & 12: Photo Showing Teeth & Alveolar Bone Embedded in Buccal Mucosa

CASE 5

Figure 10: Radiograph Showing Foreign Body & Fracture Mandible

RESULTS

A total of 20 cases were recorded in our study ,all the patients were locals from villages.Thirteen(13) were males

patients were males seven(7)were females.. [table 1] Fourteen (.14) patients belonged to older age group elderly between

50 to 70 yrs],6 patients were between 30-45 yrs of age. [TABLE 2] M ost cases from October to march ,single bears were

involved in all attacks,no defence mechanism was used except one. ALL pateients had soft tissue facial & salp lacerations

superficial & deep ,among other visceral lnjuries, Thoracic & abdominal injuries were seen in 2 patients [TABLE 3]. 15

patients were referred from various hospitals with in 24 hrs to one week 5 patients were received after 3 weeks of injury

[TABLE 4] Bony injuries of face was recorded in all patients with mandible fracture in 16 0ut of 20 cases followed by



midface fractures including maxilla ,zygomatic bones in 18 patients, salp injuries in 8 patients 3 dentoalveolar fractures

{ TABLE 5 .]Penetrating injuries in 2 patients with teeth & foeiegn bodies inside, facial nerve injuries in 2 patients, .fatal

injury 1 patient, Disfiguring scars Were seen in all 5patients who repoted after three weeks

Table 1

Table 2



Table 3

Table 4



Table 5

DISCUSSIONS

The Asiatic black bear (Urses thi betnanus) is also called as Tibetan black bear or Himalayan black bear is a

omnivorous mammal .This animal has been declared as threatened animal and didn’t come in contact with humans so

oftenly .MIDDAUGH[5],reported 105 cases durinr period of 85 years .IN our study study 20 cases were recorded in one

year august 2012 to October 2013..The bear maul injuries are on rising trends for last decade & more attacks have been

reported from villages which are populated rather than forests ,showing migration of bears to villages due to decrease in

bear territory.Recent decrease in forest areas especially outside the protected areas ,caused by fragmentation of forests

,overgrazing, treefelling ,fire conversion & overextaction of forest resources have threatened bear survival thus leading to

increased human & bear encounters[1].[R A DIETER]

IN our study all the victims were locals who had gone to graze their cattles & bring wood & food during day time

for their domestic animals .Most of the attacks were during daytime 12pm to 6pm in accordance with[ DIVIDI]7]. .Most of

the attacks took place during winter season,.this is because of the reason that due to heavy snow falls bear migrats from

mountain tops to down in serch of food & shelter ,.due to decrease in bear territory & encroachments by humans

encounters take place [BARGALI ET AL[6]]. reported Most attacks were in monsoon season from july to November

single bear was responsible for the attack in all our cases ..MIDDAUGH [5],TOUGH & BUTT [8] Repoted sow with cubs

responsible for 23.8%& 20.96% injuries in their studies.

In our study male 65% victims were males &35% females, not much difference, .ROSE & BUTT[9] reported

81% injuries in males .,RASOOL,A [10] reproted 80.33% victims males,this shows that females are also involved now a

days in outdoor activity.70% ,in our study. the victims belong middle to old age group,30% were from 30 to 45years

[..HERRERO].[11] & MIDDAUGH[5] in their study reported 71% of victims were adults..this may be beause of changing

trends of adult generation involving themselves in education ,employment & business and middle & old generation taking

care of farms & domestic affair



Physical injuriries; The physical injuries by animals vary from minor scratches to fatal wounds .no part in human

body is protected from animal attack. BARGALI et al[6] reported 8% of bear attacks were fatal.,Most victims were

attacked on their legs12.4%,,11% on other parts of body.IN a study of mammalian injuries, the hands& wrists were most

common involved sites as 36% followed by face ,head & neck 22.6% & arms 13.7%.[MACBEAN][12]… ROSE[9] noted

only had skull fractureS &four others had extremity fractures with no fracture of face at all. TOUGH & Butt

REPORTED[8] only patients having facial fractures while most of the victims had suffered cervical spine fractures .IN our

series face & scalp were most commonly involved parts of body. Face & jaws were affected in 95% .scalp & upper limbs

in 20% & 10% thoracic & abdominal injuries..Most of the cases reported in literature are head & face injuries.. this

explains the fact that head & face are most prominent parts of body there by making facial parts easily available for paws

of bear ,animal trying to weaken their enemy by easily targeting their face so that they are unable to fight back…in

accordance with [ DVIVEDI[7].In the skull frontal bone 95.83% & in face 45.13% ..

In the skull frontal bone 95.83% & in face 45.13% zygoma were commonly involved bones.[DVIVEDI[7]] Brain

injuries were reported by HAYASHI ET AL & VOUGHOUSKLAKIS ET AL[13][,14],.[ROSE][9] reported one case of

brain injury & fractures in 50% 0f his cases.

Among facial fractures 18 out of 20 cases had mandible fractures, 80% cases. Midface fracture including zygoma

was fractured in 75% with scalp injuries 45% of cases in our study, contrary to [DIVED [8I]Who showed midface

including orbit ,zygoma ,maxilla &nasal bone involvement. [SHAH AA][15] in his series have shown involvement of

midface at large & Mandible fracture in only 1-2% RANGILA RAM[4]] in his study has shown involvement of soft tissue

of face ,nasal & oral cavity, avulsion of upper anterior teeth ,multiple fractures of maxillary bone with commiuntion on left

side, comminuted fracture of hard palate ,complete fracture of maxillary sinus nasal bone temporal & zygomatic bone

fractures. The facial bones (27.09%) were commonly involved, followed by the skull (5.75%). Predominance of zygoma in

the face and frontal bone in the skull explains the fact that the most prominent parts are easily targeted. Stefanopoulos PK[

16]

The unusual injuries reported in our study in 5 cases who reported very late for the treatment ,these injuries had

gone un noticed while primary management were Fracture mandible angle with presence of a large foreign body & one

patient had fracture maxilla with dentoalveolar fracture & alveolar bone & teeth were embded in buccal mucosa, fact

supported by [RANGILA RAMA[4] who described that these injuries are as result of substantial struggle on part of victim

on ground which forces mud grass & other contaminating material into the wound.. Only one patient had fatal injury

,trcheaostomy was done & she survived,was refefred to us with disfigured scar & malunited fracture mandible.

HERRERO] has reported 500 black bear attacks,resulting in three fatalties.In a study of bear mauling from Alaska by

ROSE[9],there were 28 fatal mauling by bear attacks resulting in three fatalties .[FLOYD[17]reported that brown bear

attacks tend to be more sever ,where as black bear attacks usually result in minor injuries. Facial nerve palsy was seen in

two patients who also suffered visceral (thoracic & abdominal) injuries in our study... Two studies BY [SAMPATH

CHANDRA PRASAD[18][ SHAH AA[15] have shown involvement of facial nerve with involvement of parotid salivary

gland explaining the cause of facial nerve injury, Where as in our study facial lacerations may be the cause of facial nerve

injury supported by NEELIMA MALIK[19] .[TAWSEEF MASOUD et al][20[ in their study have shown the pattern of

occular injuries ranging from extraoccular injuries with intact globe to an extremely serious injury with avulsion of

globe.In our study extra ocular laceration were seen in 5 patients, permanent loss of vision & globe demage in one patient



,opthomologist decided to remove whole of eye but patient didn’t give consent for removel of eye ,,,) in our study… sever

.disfiguring scar & malunited fractures of faces were observed in five patient .there is need to be aware of nature of

injuries,proper time of referral is required in order to prevent facial & aesthetic disfigurement & psychological problems at

latter stages

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Prasad,case reports in otolaryngology vol 2013 (2013),Article ID 957251,5

pages,dx.doi.org/10.1152/2013/957251

19. Neelima Mlik Text book of oral & Maxillofacial surgery third edition

20. Masud T ,Sajjad S Lone IA ,Masud M, Indian journal of medical specialities july 2013..DOI

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UNUSUAL BEAR MAUL INJURIES - TJPRC...midface which being the most prominent part of face. The goal of the present study was to report Unusual injuries on other parts of face like mandible,