Maxillofacial Trauma SHANTI

8/6/2019 Maxillofacial Trauma SHANTI

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MAXILLOFACIAL TRAUMA

DR.SHANTI


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Etiology and Incidence

Multisystem injury 20-50%

Nasal and mandibular fractures most common

Midface and zygomatic injuries 2nd most

common

25% of women with facial trauma result ofdomestic violence

Incidence of concomitant cervical spine injurieswith facial fractures


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Causes of Mortality

Acute

Airway compromise

Exsanguination(severe bleeding) Associated intracranial or cervical-spine injury

Delayed

Meningitis

Oropharyngeal infections


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Pathophysiology

High Impact: Supraorbital rim 200 G

Symphysis of the Mandible 100 G Frontal 100 G

Angle of the mandible 70 G

Low Impact:

Zygoma 50 G Nasal bone 30 G


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Anatomy


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Anatomy


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Physical 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


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Inspect the nose for asymmetry,telecanthus(abnormally increased distancebetween the medial canthi of the eyelids),

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 andtemporal bone.


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Check facial stability.

Inspect the teeth for malocclusions, bleeding

Intraoral examination: Manipulation of each tooth.

Check for lacerations.

Stress the mandible.

Tongue blade test.

Palpate the mandible for tenderness, swellingand step-off.


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Check visual acuity.

Check pupils for roundness and reactivity.

Examine the eyelids for lacerations. Test extra ocular muscles.

Palpate around the entire orbits..


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Examine the cornea for abrasions and

lacerations.

Examine the anterior chamber for blood orhyphema(bleeding in the anterior chamber(the space between the cornea and the iris) of

the eye.)

Perform fundoscopic exam and examine the

posterior chamber and the retina.


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Frontal Sinus/ Bone FracturesPathophysiology

Results from a direct blow to the frontal bone

with blunt object.

Associated with:

Intracranial injuries

Injuries to the orbital roof Dural tears


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Frontal Sinus/ Bone Fractures

Clinical Findings

Disruption orcrepitance orbital rim

Subcutaneousemphysema

Associated with alaceration


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Diagnosis

Radiographs:

Facial views should

include Waters,Caldwell and lateralprojections.

Caldwell view bestevaluates the anteriorwall fractures.


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Diagnosis

CTHead with bonewindows:

Frontal sinus fractures. Orbital rim and

nasoethmoidalfractures.


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Frontal Sinus/ Bone FracturesTreatment

Patients with depressed skull fractures or with

posterior wall involvement IV antibiotics.

Tetanus.

Patients with isolated anterior wall fractures,

nondisplaced fractures can be treated outpatientafter consultation with neurosurgery.


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Frontal Sinus/ Bone FracturesComplications

Associated with intracranial injuries:

Orbital roof fractures. Dural tears.

Mucopyocoele.

Epidural empyema.

CSF leaks.

Meningitis.


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Naso-Ethmoidal-Orbital

Fracture Fractures that extend

into the nose through theethmoid bones.

Associated with lacrimaldisruption and duraltears.

Suspect if there is trauma

to the nose or medialorbit.

Patients complain of painon eye movement.


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Fracture Clinical findings:

Flattened nasal bridge or a saddle-shapeddeformity of the nose.

Widening of the nasal bridge (telecanthus)

CSF rhinorrhea or epistaxis.

Tenderness, crepitus, and mobility of the nasalcomplex.

Intranasal palpation reveals movement of themedial canthus.


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Fracture Imaging studies:

Plain radiographs are insensitive.

CT of the face with coronal cuts through themedial orbits.

Treatment:

Maxillofacial consultation.

Antibiotic


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Nasal Fractures

Most common of all facial fractures.

Injuries may occur to other surrounding bony

structures. 3 types:

Depressed

Laterally displaced

Nondisplaced


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Nasal Fractures

Clinical findings:

Nasal deformity

Edema and tenderness Epistaxis

Crepitus and mobility


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Nasal Fractures

Diagnosis:

History and physical

exam. Lateral or Waters view

to confirm yourdiagnosis.


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Nasal Fractures

Treatment:

Control epistaxis.

Drain septalhematomas(it maybecome infected andpainful and develop aseptal abscess

Nasal bone reduction


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Orbital Blowout Fractures

Blow out fractures are the most common.

Occur when the the globe sustains a direct

blunt force

2 mechanisms of injury: Blunt trauma to the globe

Direct blow to the

infraorbital rim


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Clinical Findings Periorbital tenderness,

swelling,

ecchymosis(bruise) Enopthalmus or sunken

eyes.

Impaired ocular

motility. Infraorbital anesthesia.

Step off deformity


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Imaging studies Radiographs:

Hanging tear drop sign

Open bomb bay door Air fluid levels

Orbital emphysema


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Imaging studies CT of orbits

Details the orbital

fracture Excludes retrobulbar

hemorrhage.

CTHead

R/o intracranial injuries


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Treatment Blow out fractures require

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 furthercare.


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Zygoma 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)


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Zygoma 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.


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Zygoma Arch Fractures

Clinical Findings Palpable bony defect

over the arch

Depressed cheekwith tenderness

Pain in cheek and jawmovement

Limited mandibularmovement


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Zygoma Arch Fractures

Imaging Studies & Treatment Radiographic

imaging:

Submental view(bucket handle view)

Treatment:

Ice and analgesia

Possible openelevation


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Zygoma Tripod Fractures Tripod fractures

consist of fractures

through: Zygomatic arch

Zygomaticofrontalsuture

Inferior orbital rim andfloor


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Tripod Fracture


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Zygoma Tripod Fractures

Clinical Features Clinical features:

Periorbital edema and

ecchymosis(bruise) Hypesthesia (sensory

loss )of the infraorbitalnerve

Palpation may revealstep off

Concomitant globeinjuries are common


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Imaging Studies Radiographic

imaging:

Waters, Submentaland Caldwell views

Coronal CT of thefacial bones:

3-D reconstruction


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Treatment Nondisplaced fractures without eye involvement

Ice and analgesics

operative consideration within 5-7 days

Decongestants

Broad spectrum antibiotics

Tetanus

Displaced tripod fractures usually require openreduction and internal fixation.


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Maxillary Fractures

High energy injuries.

Impact 100 times the force of gravity is

required . Patients often have significant multisystem

trauma.

Classified as LeFort fractures.


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LeFort Fractures


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Maxillary Fractures

LeFort I Definition:

Horizontal fracture of

the maxilla at the levelof the nasal fossa.

Allows motion of themaxilla while the nasalbridge remains stable.


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Maxillary Fractures

LeFort I Clinical findings:

Facial edema

Malocclusion of theteeth

Motion of the maxillawhile the nasal bridge

remains stable


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Maxillary Fractures

LeFort I 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


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Maxillary Fractures

LeFort II Definition:

Pyramidal fracture

Maxilla Nasal bones

Medial aspect of theorbits


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Maxillary Fractures

LeFort II Clinical findings:

Marked facial edema

Nasal flattening Traumatic telecanthus

Epistaxis or CSFrhinorrhea

Movement of theupper jaw and thenose.


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Maxillary Fractures

LeFort II Radiographic

imaging:

Fracture involves: Nasal bones

Medial orbit

Maxillary sinus

Frontal process of the

maxilla

CT of the face andhead


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Maxillary Fractures

LeFort III Definition:

Fractures through:

Maxilla Zygoma

Nasal bones

Ethmoid bones

Base of the skull


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Maxillary Fractures

LeFort III Clinical findings:

Dish faced deformity

Epistaxis and CSFrhinorrhea

Motion of the maxilla,nasal bones andzygoma

Severe airwayobstruction


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Maxillary Fractures

LeFort III Radiographic

imaging:

Fractures through: Zygomaticfrontal suture

Zygoma

Medial orbital wall

Nasal bone

CT Face and the Head


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Maxillary Fractures

Treatment Secure and airway

Control Bleeding

Head elevation 40-60 degrees antibiotics

Reduction,fixation and recontruction done


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Mandible Fractures

Pathophysiology Mandibular fractures are

the third most commonfacial fracture.

Assaults and falls on thechin account for most ofthe injuries.

Multiple fractures are

seen in greater then 50%.


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Mandible Fractures

Clinical findings Mandibular pain.

Malocclusion of the teeth

Separation of teeth withintraoral bleeding

Inability to fully openmouth.

Preauricular pain with

biting. Positive tongue blade

test.


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Mandible Fractures

Radiographs:

Panoramic view

Plain view: PA, Lateral and a Townes view


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Mandibular Fractures

Treatment Nondisplaced fractures:

Analgesics

Soft diet

oral surgery

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

All fractures should be treated with antibioticsand tetanus prophylaxis.


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Mandibular 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


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The mandible can bedislocated:

Anterior 70% Posterior

Lateral

Superior

Dislocations aremostly bilateral.


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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


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Clinical features:

Inability to close

mouth Pain

Facial swelling

Physical exam:

Palpable depression Jaw will deviate away

Jaw displaced anterior


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Treatment:

Muscle relaxant

Analgesic Closed reduction


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Emergency Management

Intubation Considerations Avoid nasotracheal intubation:

Nasocranial intubation

Nasal hemorrhage Avoid Rapid Sequence

Intubation:

Failure to intubate or ventilate.

Consider an awake intubation.

Sedate with benzodiazepines.


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Intubation Considerations Consider fiberoptic intubation if available.

Alternatives include percutaneous

transtracheal ventilation and retrogradeintubation.

Be prepared for cricothyroidotomy.


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Hemorrhage Control Maxillofacial bleeding:

Direct pressure.

Avoid blind clamping in wounds.

Nasal bleeding: Direct pressure.

Anterior and posterior packing.

Pharyngeal bleeding: Packing of the pharynx around ET tube.


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Thank you

Maxillofacial Trauma SHANTI

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