Maxillofacial trauma

Features of the maxillofacial area (MFA) Features of the maxillofacial area (MFA) injuries. Classification, debridement of injuries. Classification, debridement of

soft tissue wounds MFA. Nongunshot soft tissue wounds MFA. Nongunshot damage of the lower and upper jaws: damage of the lower and upper jaws:

Anatomy injury, pathogenesis, Anatomy injury, pathogenesis, classification, statistics, symptoms, classification, statistics, symptoms,

diagnosis, transportation diagnosis, transportation immobilization. Damage to the immobilization. Damage to the zygomatic bone, nasal bones in zygomatic bone, nasal bones in

peacetime: classification, incidence, peacetime: classification, incidence, clinical features, diagnosis and clinical features, diagnosis and

treatment.treatment.

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Maxillofacial traumaMaxillofacial trauma

Management of traumatized patient

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Organization of trauma servicesOrganization of trauma services

Pre-hospital care (field triage) Care delivered by fully trained paramedic in maintaining airway, controlling

cervical spine, securing intravenous and initiating fluid resuscitation

Hospital care (inter-hospital triage) Senior medical staff organized team to ensure that medical resources are

deployed to maximum overall benefit

Mass casualty triage

triage decisions are crucial in triage decisions are crucial in determining individual patients survivaldetermining individual patients survival

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Primary surveyPrimary survey

Ⓐ Airway maintenance with cervical spine control

Ⓑ Breathing and ventilation

Ⓒ Circulation with hemorrhage control

Ⓓ Disability assessment of neurological status

Ⓔ Exposure and complete examination of the patient

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AirwayAirway

Satisfactory airway signifies the implication of breathing and ventilation and cerebral function

Management of maxillofacial trauma is an integral part in securing an unobstructed airway

Immobilization in a natural position by a semi-rigid collar until damaged spine is excluded

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Is the patient fully conscious? And able to maintain adequate airway?

Semiconscious or unconscious patient rapidly suffocate because of inability to cough and adopt a posture that held tongue forward

Sequel of facial injurySequel of facial injury

Obstruction of airway

asphyxia

Cerebral hypoxia

Brain damage/ death

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Breathing and ventilationBreathing and ventilationChest injuries:

Pneumothorax, haemopneumothorax, flail segments, reputure daiphram, cardiac tamponade

signs

Clinical Deviated trachea

Absence of breath sounds

Dullness to percussionParadoxical movementsHyper-response with a large pneumothoraxMuffled heart sounds

RadiographicalLoss of lung markingDeviation of trachea

Raised hemi-diaphragmFluid levels

Fracture of ribs

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Circulation Circulation

Circulatory collapse leads to low blood pressure, increasing pulse rate and diminished capillary

filling at the periphery

Patient resuscitationPatient resuscitationRestoration of cardio-respiratory functionRestoration of cardio-respiratory function

Shock managementShock managementReplacement of lost fluidReplacement of lost fluid

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Glasgow coma scale (GCS)Glasgow coma scale (GCS)(Teasdale and Jennett, 1974)(Teasdale and Jennett, 1974)

Eye Eye openingopening

Motor Motor responseresponse

Verbal Verbal responseresponse

SpontaneousSpontaneous 44 Move to Move to commandcommand

66 ConverseConverse 55

To speechTo speech 33 Localizes to Localizes to painpain

55 ConfusedConfused 44

To painTo pain 22 Withdraw Withdraw from painfrom pain

44 GibberishGibberish 33

nonenone 11 flexesflexes 33 gruntsgrunts 22

ExtendsExtends 22 nonenone 11nonenone 11

Score 8 or less indicates poor prognosis, moderate head injury between 9-12 and mild refereed to 13-15

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Exposure Exposure

All trauma patient must be fully exposed in a warm environment to disclose any other hidden

injuries

When the airway is adequately secured the second survey of the whole body is to be carried out for:

Accurate diagnosis Maintenance of a stable state Determination of priorities in treatment Appropriate specialist referral

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Head injuryHead injury

Many of facial injury patients sustain head Many of facial injury patients sustain head injury in particular the mid face injuriesinjury in particular the mid face injuries

Open

Closed

it is ranged from Mild concussion to brain death

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Signs and symptoms of head injurySigns and symptoms of head injury Loss of conscious OR History of loss of conscious History of vomiting Change in pulse rate, blood pressure and pupil reaction to

light in association with increased intracranial pressure

Assessment of head injury (behavioral responses “motor and verbal responses” and eye opening)

Skull fracture Skull base fracture (battle’s sign) Temporal/ frontal bone fracture Naso-orbital ethmoidal fracture

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slow reaction and fixation of dilated pupil denotes a rise in intra-cranial pressure

Rise in intercranial pressure as a result of acute subdural or extradural hemorrhage deteriorate the

patient’s neurological status

Apparently stable patient with suspicion of head injury must be monitored at intervals up to one hour for 24 hour after the

trauma

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Hemorrhage Hemorrhage

Acute bleeding may lead to hemorrhagic shock and circulatory collapse

Abdominal and pelvis injury; liver and internal organs injury (peritonism)

Fracture of the extremities (femur)

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Preliminary treatment in complex Preliminary treatment in complex facial injuryfacial injury

Soft tissue laceration (8 hours of injury with no delay beyond 24 hours)

Support of the bone fragments

Injury to the eye As a result of trauma, 1.6 million are blind, 2.3 million are

suffering serious bilateral visual impairment and 19 million with unilateral loss of sight (Macewen 1999)

Ocular damage Reduction in visual acuity Eyelid injury

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Prevention of infectionPrevention of infectionFractures of jaw involving teeth bearing areas Fractures of jaw involving teeth bearing areas are compound in nature and midface fracture are compound in nature and midface fracture

may go high, leading to CSF leaks may go high, leading to CSF leaks (rhinorrhoea, otorrhoea) and risk of meningitis,(rhinorrhoea, otorrhoea) and risk of meningitis,

and in case of perforation of cartilaginous and in case of perforation of cartilaginous auditory canalauditory canal

Diagnosis: Laboratory investigation, CT and MRI scan Management:

– Dressing of external wounds– Closure of open wounds– Reposition and immobilization of the fractures– Repair of the dura matter– Antibacterial prophylaxis (as part of the general management (Eljamal,

1993)

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Control of painControl of pain Displaced fracture may cause severe pain but Displaced fracture may cause severe pain but

strong analgesic ( Morphine and its derivatives) strong analgesic ( Morphine and its derivatives) must be avoided as they depress cough reflex, must be avoided as they depress cough reflex, constrict pupils as they may mask the signs of constrict pupils as they may mask the signs of

increasing intracranial pressureincreasing intracranial pressure

Management:

☞ Non-steroidal anti-inflammatory drugs can be prescribed (Diclofenac acid)

☞ Reduction of fracture

☞ sedation

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In patient careIn patient care

Necessary medications

Diet (fluid, semi-fluid and solid food) intake and output (fluid balance chart)

Hygiene and physiotherapy

Proper timing for surgical intervention

AnatomyAnatomy

Physical ExaminationPhysical Examination

Inspection of the face for asymmetry.Inspect open wounds for foreign bodies.Palpate the entire face.

– Supraorbital and Infraorbital rim– Zygomatic-frontal suture– Zygomatic arches


Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge.

Inspect nasal septum for septal hematoma, CSF or blood.

Palpate nose for crepitus, deformity and subcutaneous air.

Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone.


Check facial stability. Inspect the teeth for malocclusions, bleeding and

step-off. Intraoral examination:

– Manipulation of each tooth.– Check for lacerations.– Stress the mandible.– Tongue blade test.

Palpate the mandible for tenderness, swelling and step-off.


Check visual acuity.Check pupils for roundness and reactivity.Examine the eyelids for lacerations.Test extra ocular muscles.Palpate around the entire orbits..


Examine the cornea for abrasions and lacerations.

Examine the anterior chamber for blood or hyphema.

Perform fundoscopic exam and examine the posterior chamber and the retina.


Examine and palpate the exterior ears.Examine the ear canals.Check nuero distributions of the

supraorbital, infraorbital, inferior alveolar and mental nerves.

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesPathophysiologyPathophysiology

Results from a direct blow to the frontal bone with blunt object.

Associated with:– Intracranial injuries– Injuries to the orbital roof– Dural tears

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesClinical FindingsClinical Findings

Disruption or crepitance orbital rim

Subcutaneous emphysema

Associated with a laceration

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesDiagnosisDiagnosis

Radiographs:– Facial views should

include Waters, Caldwell and lateral projections.

– Caldwell view best evaluates the anterior wall fractures.

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesDiagnosisDiagnosis

CT Head with bone windows:– Frontal sinus fractures. – Orbital rim and

nasoethmoidal fractures.

– R/O brain injuries or intracranial bleeds.

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesTreatmentTreatment

Patients with depressed skull fractures or with posterior wall involvement.– ENT or nuerosurgery consultation.– Admission.– IV antibiotics.– Tetanus.

Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesComplicationsComplications

Associated with intracranial injuries:– Orbital roof fractures.– Dural tears.– Mucopyocoele.– Epidural empyema.– CSF leaks.– Meningitis.

Naso-Ethmoidal-Orbital Naso-Ethmoidal-Orbital FractureFracture

Fractures that extend into the nose through the ethmoid bones.

Associated with lacrimal disruption and dural tears.

Suspect if there is trauma to the nose or medial orbit.

Patients complain of pain on eye movement.


Clinical findings:– Flattened nasal bridge or a saddle-shaped

deformity of the nose.– Widening of the nasal bridge (telecanthus)– CSF rhinorrhea or epistaxis.– Tenderness, crepitus, and mobility of the nasal

complex.– Intranasal palpation reveals movement of the

medial canthus.


Imaging studies:– Plain radiographs are insensitive.– CT of the face with coronal cuts through the

medial orbits.

Treatment:– Maxillofacial consultation.– ? Antibiotic

Nasal FracturesNasal Fractures

Most common of all facial fractures.Injuries may occur to other surrounding

bony structures.3 types:

– Depressed– Laterally displaced– Nondisplaced


Ask the patient:– “Have you ever broken your nose before?”– “How does your nose look to you?”– “Are you having trouble breathing?”


Clinical findings:– Nasal deformity– Edema and tenderness– Epistaxis– Crepitus and mobility


Diagnosis:– History and physical

exam.– Lateral or Waters view

to confirm your diagnosis.


Treatment:– Control epistaxis.– Drain septal

hematomas.– Refer patients to ENT

as outpatient.

Orbital Blowout FracturesOrbital Blowout Fractures

Blow out fractures are the most common.Occur when the the globe sustains a direct

blunt force2 mechanisms of injury:

– Blunt trauma to the globe– Direct blow to the infraorbital rim

Orbital Blowout FracturesOrbital Blowout FracturesClinical FindingsClinical Findings

Periorbital tenderness, swelling, ecchymosis.

Enopthalmus or sunken eyes.

Impaired ocular motility.

Infraorbital anesthesia. Step off deformity

Orbital Blowout FracturesOrbital Blowout FracturesImaging studiesImaging studies

Radiographs:– Hanging tear drop sign– Open bomb bay door– Air fluid levels– Orbital emphysema

Orbital Blowout FracturesOrbital Blowout FracturesImaging studiesImaging studies

CT of orbits– Details the orbital

fracture– Excludes retrobulbar

hemorrhage.

CT Head– R/o intracranial

injuries

Orbital Blowout FracturesOrbital Blowout FracturesTreatmentTreatment

Blow out fractures without eye injury do not require admission– Maxillofacial and ophthalmology consultation– Tetanus– Decongestants for 3 days– Prophylactic antibiotics– Avoid valsalva or nose blowing

Patients with serious eye injuries should be admitted to ophthalmology service for further care.

Zygoma FracturesZygoma Fractures

The zygoma has 2 major components:– Zygomatic arch– Zygomatic body

Blunt trauma most common cause.Two types of fractures can occur:

– Arch fracture (most common)– Tripod fracture (most serious)

Zygoma Arch FracturesZygoma Arch Fractures

Can fracture 2 to 3 places along the arch– Lateral to each end of the arch– Fracture in the middle of the arch

Patients usually present with pain on opening their mouth.

Zygoma Arch FracturesZygoma Arch FracturesClinical FindingsClinical Findings

Palpable bony defect over the arch

Depressed cheek with tenderness

Pain in cheek and jaw movement

Limited mandibular movement

Zygoma Arch FracturesZygoma Arch FracturesImaging Studies & TreatmentImaging Studies & Treatment

Radiographic imaging:– Submental view

(bucket handle view)

Treatment:– Consult maxillofacial

surgeon– Ice and analgesia– Possible open elevation

Zygoma Tripod FracturesZygoma Tripod Fractures

Tripod fractures consist of fractures through:– Zygomatic arch– Zygomaticofrontal

suture– Inferior orbital rim and

floor

Zygoma Tripod FracturesZygoma Tripod FracturesClinical FeaturesClinical Features

Clinical features:– Periorbital edema and

ecchymosis– Hypesthesia of the

infraorbital nerve– Palpation may reveal

step off– Concomitant globe

injuries are common

Zygoma Tripod FracturesZygoma Tripod FracturesImaging StudiesImaging Studies

Radiographic imaging:– Waters, Submental and

Caldwell views

Coronal CT of the facial bones:– 3-D reconstruction

Zygoma Tripod FracturesZygoma Tripod FracturesTreatmentTreatment

Nondisplaced fractures without eye involvement– Ice and analgesics– Delayed operative consideration 5-7 days– Decongestants – Broad spectrum antibiotics – Tetanus

Displaced tripod fractures usually require admission for open reduction and internal fixation.

Maxillary FracturesMaxillary Fractures

High energy injuries.Impact 100 times the force of gravity is

required .Patients often have significant multisystem

trauma.Classified as LeFort fractures.

Maxillary FracturesMaxillary FracturesLeFort ILeFort I

Definition:– Horizontal fracture of

the maxilla at the level of the nasal fossa.

– Allows motion of the maxilla while the nasal bridge remains stable.


Clinical findings:– Facial edema– Malocclusion of the

teeth– Motion of the maxilla

while the nasal bridge remains stable


Radiographic findings:– Fracture line which

involves Nasal aperture Inferior maxilla Lateral wall of maxilla

CT of the face and head – coronal cuts– 3-D reconstruction

Maxillary FracturesMaxillary FracturesLeFort IILeFort II

Definition:– Pyramidal fracture

Maxilla Nasal bones Medial aspect of the

orbits


Clinical findings:– Marked facial edema– Nasal flattening– Traumatic telecanthus– Epistaxis or CSF

rhinorrhea – Movement of the upper

jaw and the nose.


Radiographic imaging:– Fracture involves:

Nasal bones Medial orbit Maxillary sinus Frontal process of the

maxilla

CT of the face and head

Maxillary FracturesMaxillary FracturesLeFort IIILeFort III

Definition:– Fractures through:

Maxilla Zygoma Nasal bones Ethmoid bones Base of the skull


Clinical findings:– Dish faced deformity– Epistaxis and CSF

rhinorrhea – Motion of the maxilla,

nasal bones and zygoma

– Severe airway obstruction


Radiographic imaging:– Fractures through:

Zygomaticfrontal suture Zygoma Medial orbital wall Nasal bone

CT Face and the Head

Maxillary FracturesMaxillary FracturesTreatmentTreatment

Secure and airwayControl BleedingHead elevation 40-60 degreesConsult with maxillofacial surgeonConsider antibioticsAdmission

Mandible FracturesMandible FracturesPathophysiologyPathophysiology

Mandibular fractures are the third most common facial fracture.

Assaults and falls on the chin account for most of the injuries.

Multiple fractures are seen in greater then 50%.

Associated C-spine injuries – 0.2-6%.

Mandible FracturesMandible FracturesClinical findingsClinical findings

Mandibular pain. Malocclusion of the teeth Separation of teeth with

intraoral bleeding Inability to fully open

mouth. Preauricular pain with

biting. Positive tongue blade test.

Mandible FracturesMandible Fractures

Radiographs:– Panoramic view– Plain view: PA, Lateral and a Townes view

Mandibular FracturesMandibular FracturesTreatmentTreatment

Nondisplaced fractures:– Analgesics– Soft diet– oral surgery referral in 1-2 days

Displaced fractures, open fractures and fractures with associated dental trauma– Urgent oral surgery consultation

All fractures should be treated with antibiotics and tetanus prophylaxis.

Mandibular DislocationMandibular Dislocation

Causes of mandibular dislocation are:– Blunt trauma– Excessive mouth opening

Risk factors:– Weakness of the temporal mandibular ligament– Over stretched joint capsule – Shallow articular eminence– Neurologic diseases


The mandible can be dislocated:– Anterior 70%– Posterior– Lateral– Superior

Dislocations are mostly bilateral.


Posterior dislocations:– Direct blow to the chin– Condylar head is pushed against the mastoid

Lateral dislocations:– Associated with a jaw fracture– Condylar head is forced laterally and superiorly

Superior dislocations:– Blow to a partially open mouth– Condylar head is force upward


Clinical features:– Inability to close

mouth– Pain– Facial swelling

Physical exam:– Palpable depression– Jaw will deviate away– Jaw displaced anterior


Diagnosis:– History & Physical

exam– X-rays– CT


Treatment:– Muscle relaxant– Analgesic– Closed reduction in the

emergency room


Treatment:– Oral surgeon consultation:

Open dislocations Superior, posterior or lateral dislocations Non-reducible dislocations Dislocations associated with fractures


Disposition:– Avoid excessive mouth opening– Soft diet– Analgesics– Oral surgery follow up

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Maxillofacial trauma

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