PowerPoint Maxillofacial Trauma English

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Joe Lex, MD, FACEP, FAAEM Temple University School of Medicine Philadelphia, PA USA [email protected] du Maxillofacial Trauma

Transcript of PowerPoint Maxillofacial Trauma English

Joe Lex, MD, FACEP, FAAEMTemple University School of Medicine

Philadelphia, PA USA

[email protected]

Maxillofacial Trauma

Lecture Outline

• Emergency management

• Facial exam

• Fractures– Major

– Minor

• Soft tissue injuries

• Unusual injuries

Causes of Mortality

• Acute– Airway compromise

– Exsanguination

– Associated intracranial or cervical-spine injury

• Delayed– Meningitis

– Oropharyngeal infections

Epidemiology

• Estimated 3,000,000 facial trauma cases per year in USA

• Estimated 40 to 50% of motor vehicle victims have facial injury

• No uniform reporting or registry of cases

Functions of Face

• Respiratory upper airway

• Visual

• Olfactory

• Mastication

• Cosmetic

• Communication

• Individual recognition

Management Sequence

• Airway control / immobilize cervical spine

• Bleeding control

• Complete the primary survey

• Secondary survey– Consider NG or OG tube placement

Management Sequence

• Plain radiographs if fractures suspected

• CT if suspect complex fractures

Management Sequence

• Repair soft tissue immediately if no other injuries

• Delay soft tissue repair until patient in OR if surgery for other injuries necessary

Initial Management

Step 1: Airway control

• Oxygen for all patients

• May need to keep patient sitting or prone

• Stabilize C-spine early

• Large bore (Yankauer) suction available

Initial Management

Step 1: Airway control

• Orotracheal intubation preferred over nasotracheal if possible midfacial fracture and invasive airway needed

• Combitube®, retrograde wire, or cricothyroidostomy if unable to orotracheally intubate

Initial Management

Step 2 : Bleeding control

• Can be major threat to life

• Use universal precautions

• Direct pressure dressings initially

• Contraindicated: blind vessel clamping

Initial Management

Step 2 : Bleeding control

• Rapid nasal packing may be necessary– Be sure blood is not just running

down posterior pharynx

Initial Management

Step 2 : Bleeding control

• Rarely: emergent cutdown and ligation of external carotid artery needed to prevent exsanguination

• Note: Although shock in facial trauma patient is usually due to other injuries, it is possible to bleed to death from a facial injury

Airway Compromise

• Blood in airway

• “Debris” in airway– Vomitus, avulsed tissue, teeth or

dentures, foreign bodies

• Pharyngeal or retropharyngeal tissue swelling

• Posterior tongue displacement from mandible fractures

Secondary Survey

Scalp

• Check for lacerations, hematomas, stepoffs, tenderness

• Bleeding maybe brisk until sutured

• Can use stapler for rapid closure

Secondary Survey

Ears

• Examine pinnae, canal walls, tympanic membranes

• Suction gently under direct vision if blood in canal

• Put drop of canal fluid on filter paper for “ring sign” CSF leak

• Assess hearing

Secondary Survey

Eyes

• Pupils, anterior chamber, fundi, extraocular movements

• Conjunctivae for foreign bodies

• Palpate orbital rims– No globe palpation if suspect

penetration

Secondary Survey

Eyes

• Lid injury can leave cornea exposed– Use artificial tears or cellulose gel

Secondary Survey

Overall facial appearance

• Assess for symmetry, deformity, discoloration, nasal alignment

• Palpate forehead & malar areas

Secondary Survey

Nose

• Check septum for hematoma & position

• Check airflow in both nares

• Palpate nasal bridge for crepitus

• Check fluid on filter paper for “ring sign” (for CSF leak)

Secondary Survey

Mouth

• Check occlusion

• Reflect upper & lower lips

• Check Stenson's duct for blood

• Palpate along mandibular and maxillary teeth (be careful !)

Secondary Survey

Mouth

• Palpate along exterior of mandible

• Pull forward on maxillary teeth

Secondary Survey

Neurologic

• Skin fold symmetry at rest

• Motor: each division of CN-VII

• Sensation: 3 divisions of CN-V

• Sensation on tongue

• Gag reflex

Fracture Classification

Major• Lefort I, II, III• Mandibular

Minor• Nasal• Sinus wall• Zygomatic• Orbital floor• Antral wall• Alveolar ridge

Forces Required

• Nasal fracture 30 g

• Zygoma fractures 50 g

• Mandibular (angle) fractures 70 g

• Frontal region fractures 80 g

• Maxillary (midline) fractures 100 g

• Mandibular (midline) fractures 100 g

• Supraorbital rim fractures 200 g

Lefort Fractures

• Lefort fractures can coexist with additional facial fractures

• Patient may have different Lefort type fracture on each side of the face

Differentiating Leforts

Pull forward on maxillary teeth

• Lefort I: maxilla only moves

• Lefort II: maxilla & base of nose move:

• Lefort III: whole face moves:

Lefort I: Nasomaxillary

• Horizontal fracture extending through maxilla between maxillary sinus floor & orbital floor– Crepitus over maxilla

– Ecchymosis in buccal vestibule

– Epistaxis: can be bilateral

– Malocclusion

– Maxilla mobility

Lefort I: Nasomaxillary

• Closed reduction

• Intermaxillary fixation: secures maxilla to mandible

• May need wiring or plating of maxillary wall and / or zygomatic arch

• Antibiotics: anti-staphylococcal

Lefort II: Pyramidal

• Subzygomatic midfacial fracture with a pyramid-shaped fragment separated from cranium and lateral aspects of face

Lefort II: Pyramidal

Signs & symptoms• Midface crepitus• Face lengthening• Malocclusion• Bilateral epistaxis• Infraorbital paresthesia• Ecchymoses: buccal vestibule,

periorbital, subconjunctival

Lefort II: Pyramidal

• Hemorrhage or airway obstruction may require emergent surgery

• Treatment can often be delayed till edema decreased

Lefort II: Pyramidal

Usually require• Intermaxillary fixation• Interosseous wiring or plating of

infraorbital rims, nasal-frontal area, & lateral maxillary walls

• May need additional suspension wires

• Antibiotics

Lefort III

• Craniofacial dissociation

• Bilateral suprazygomatic fracture resulting in a floating fragment of mid-facial bones, which are totally separated from the cranial base

Lefort III

Signs and Symptoms

• Face lengthening: “caved-in” or “donkey face”

• Malocclusion: “open bite”

• Lateral orbital rim defect

• Ecchymoses: periorbital, subconjunctival

Lefort III

Signs and Symptoms

• Bilateral epistaxis

• Infraorbital paresthesia

• Often medial canthal deformity

• Often unequal pupil height

Lefort III

• Usually associated with major soft tissue injury requiring emergent surgery for bleeding control

• Surgery can be delayed till edema resolves

• Intermaxillary fixation

Lefort III

• Transosseous wiring or plating– Frontozygomatic suture

– Nasofrontal suture

– May need extracranial fixation if concurrent mandibular fracture

• Antibiotics

Forces Required

• Nasal fracture 30 g

• Zygoma fractures 50 g

• Mandibular (angle) fractures 70 g

• Frontal region fractures 80 g

• Maxillary (midline) fractures 100 g

• Mandibular (midline) fractures 100 g

• Supraorbital rim fractures 200 g

Mandible Fractures

• Airway obstruction from loss of attachment at base of tongue

• >50 % are multiple

• Condylar fractures associated with ear canal lacerations & high cervical fractures

• High infection potential if any violation of oral mucosa

Mandible Fractures

Signs and symptoms

• Malocclusion

• Decreased jaw range of motion

• Trismus

• Chin numbness

• Ecchymosis in floor of mouth

• Palpable step deformity

Mandible Fractures

• Tongue blade test: have patient bite down while you twist. If no fracture, you will be able to break the blade.

Mandible Fractures

Treatment

• Prompt fixation: intermaxillary fixation (arch bars), +/- body wiring or plating

TMJ Dislocation

• Can occur from direct blow to mandible

• Can occur “spontaneously” from yawning or laughing

• Mandible dislocates forward & superiorly

• Concurrent masseter & pterygoid spasm

TMJ Dislocation

Symptoms

• Patient presents with mouth open, cannot close mouth or talk well

• Can be misdiagnosed as psychiatric or dystonic reaction

TMJ Dislocation

Treatment

• Manual reduction: place wrapped thumbs on molars & push downward, then backward

• Be careful not to get bitten

• Usually does not require procedural sedation or muscle relaxants

Forces Required

• Nasal fracture 30 g

• Zygoma fractures 50 g

• Mandibular (angle) fractures 70 g

• Frontal region fractures 80 g

• Maxillary (midline) fractures 100 g

• Mandibular (midline) fractures 100 g

• Supraorbital rim fractures 200 g

Nasal Bone Fractures

• Often diagnosed clinically: x-ray not needed

• Emergent reduction not necessary except to control epistaxis

• Usually do not need antibiotics

• Early reduction under local anesthesia useful if nares obstructed

Nasal Bone Fractures

• Nasal septal hematoma: incise & drain, anterior pack, antibiotics, follow-up at 24 hours

• Follow-up timing for recheck or reduction:– Children: 3 to 5 days

– Adults: 7 days

Forces Required

• Nasal fracture 30 g

• Zygoma fractures 50 g

• Mandibular (angle) fractures 70 g

• Frontal region fractures 80 g

• Maxillary (midline) fractures 100 g

• Mandibular (midline) fractures 100 g

• Supraorbital rim fractures 200 g

Zygomatic Fractures

Tripod (tri-malar) fracture

• Depression of malar eminence

• Fractures at temporal, frontal, and maxillary suture lines

Zygomatic Fractures

Isolated arch fracture

• Less common

• Shows best on submental-vertex x-ray view

• Painful mandible movement

• Usually treat with fixation wire if arch depressed

Zygomatic Fractures

Tripod S & S• Unilateral

epistaxis• Depressed malar

prominence• Subcutaneous

emphysema• Orbital rim step-

off

• Altered relative pupil position

• Periorbital ecchymosis

• Subconjunctival hemorrhage

• Infraorbital hypoesthesia

Forces Required

• Nasal fracture 30 g

• Zygoma fractures 50 g

• Mandibular (angle) fractures 70 g

• Frontal region fractures 80 g

• Maxillary (midline) fractures 100 g

• Mandibular (midline) fractures 100 g

• Supraorbital rim fractures 200 g

Supraorbital Fractures

Frontal sinus fracture

• Often associated with intracranial injury

• Often show depressed glabellar area

• If posterior wall fracture, then dura is torn

Supraorbital Fractures

Ethmoid fracture

• Blow to bridge of nose

• Often associated with cribiform plate fracture, CSF leak

• Medial canthus ligament injury needs transnasal wiring repair to prevent telecanthus

Orbital Fractures

• “Blow out” fracture of floor

• Rule out globe injury– Visual acuity

– Visual fields

– Extraocular movement

– Anterior chamber

– Fundus

– Fluorescein & slit lamp

Orbital Fractures

Symptoms and signs

• Diplopia: double vision

• Enophthalmos: sunken eyeball

• Impaired EOM’s

• Infraorbital hypesthesia

• Maxillary sinus opacification

• “Hanging drop” in maxillary sinus

Orbital Fractures

• Diplopia with upward gaze: 90%– Suggests inferior blowout

– Entrapment of inferior rectus & inferior oblique

• Diplopia with lateral gaze: 10%– Suggests medial fracture

– Restriction of medial rectus muscle

Orbital Fracture: Treatment

• Sometimes extraocular muscle dysfunction can be due to edema and will correct without surgery

• Persistent or high grade muscle entrapment requires surgical repair of orbital floor (bone grafts, Teflon, plating, etc.)

Facial Soft Tissue Injuries

• Before repair, rule out injury to:– Facial nerve

– Trigeminal nerve

– Parotid duct

– Lacrimal duct

– Medial canthal ligament

• Remove embedded foreign material to prevent tattooing

Facial Soft Tissue Rules

• For lip lacerations, place first suture at vermillion border

• Never shave an eyebrow: may not grow back

• If debridement of eyebrow laceration needed, debride parallel to angle of hairs rather than vertically

Facial Soft Tissue Rules

• Antibiotics for 3 to 5 days for any intraoral laceration (penicillin VK or erythromycin) and if any exposed ear cartilage (anti-staphylococcal antibiotic) – no evidence

• Remove sutures in 3 to 5 days to prevent cross-marks

Facial Soft Tissue Rules

• Most face bite wounds can be sutured primarily

• Clean facial wounds can be repaired up to 24 hours after injury

• Place incisions or debridement lines parallel to the lines of least skin tension (Lines of Langer)

Questions??

Summary

• Assess ABC's first

• Do complete exam as part of secondary survey

• Obtain standard X-rays and / or CT scan as indicated

• Decide if specialist referral and / or operative repair indicated

Summary

• Arrange followup after repair to assess for delayed complications or cosmetic problems