Maxillofacial Trauma Brief Overview. Physical Exam: some things to look for ► Inspection of the...

Maxillofacial TraumaMaxillofacial TraumaBrief OverviewBrief Overview

Physical Exam: Physical Exam: some things to look forsome things to look for

► Inspection of the face for asymmetry.Inspection of the face for asymmetry.► Inspect open wounds for foreign Inspect open wounds for foreign

bodies.bodies.►Palpate the entire face.Palpate the entire face.

Supraorbital and Infraorbital rimSupraorbital and Infraorbital rim Zygomatic-frontal sutureZygomatic-frontal suture Zygomatic archesZygomatic arches


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

► Inspect nasal septum for septal hematoma, Inspect nasal septum for septal hematoma, CSF or blood.CSF or blood.

► Palpate nose for crepitus, deformity and Palpate nose for crepitus, deformity and subcutaneous air.subcutaneous air.

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


► Check facial stability.Check facial stability.► Inspect the teeth for malocclusions, Inspect the teeth for malocclusions,

bleeding and step-off.bleeding and step-off.► Intraoral examination: Intraoral examination:

Manipulation of each tooth.Manipulation of each tooth. Check for lacerations.Check for lacerations. Stress the mandible.Stress the mandible.

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


► Check visual acuity.Check visual acuity.► Check pupils for reactivity.Check pupils for reactivity.► Examine the eyelids for lacerations.Examine the eyelids for lacerations.► Test extra ocular muscles.Test extra ocular muscles.► Palpate around the entire orbits.Palpate around the entire orbits.► Check neuro distributions of supraorbital, Check neuro distributions of supraorbital,

infraorbital, inferior alveolar and mental infraorbital, inferior alveolar and mental nervesnerves

Frontal Sinus Bone FracturesFrontal Sinus Bone FracturesPathophysiologyPathophysiology

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

► Associated with:Associated with: Intracranial injuriesIntracranial injuries Injuries to the orbital roofInjuries to the orbital roof Dural tearsDural tears

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesClinical FindingsClinical Findings

► Disruption or Disruption or crepitance orbital rimcrepitance orbital rim

► Subcutaneous Subcutaneous emphysemaemphysema

► Associated with a Associated with a lacerationlaceration

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesDiagnosisDiagnosis

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

nasoethmoidal fractures.nasoethmoidal fractures. R/O brain injuries or R/O brain injuries or

intracranial bleeds.intracranial bleeds.

Naso-Ethmoidal-Orbital Naso-Ethmoidal-Orbital FractureFracture

► Fractures that extend Fractures that extend into the nose through into the nose through the ethmoid bones.the ethmoid bones.

► Associated with Associated with lacrimal disruption and lacrimal disruption and dural tears.dural tears.

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

► Patients complain of Patients complain of pain on eye movement.pain on eye movement.


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

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

complex.complex. Intranasal palpation reveals movement of the Intranasal palpation reveals movement of the

medial canthus.medial canthus.


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

medial orbits.medial orbits.

Orbital Blowout FracturesOrbital Blowout Fractures

►Blow out fractures are the most Blow out fractures are the most common.common.

►Occur when the the globe sustains a Occur when the the globe sustains a direct blunt forcedirect blunt force

►2 mechanisms of injury:2 mechanisms of injury: Blunt trauma to the globeBlunt trauma to the globe Direct blow to the infraorbital rimDirect blow to the infraorbital rim

Orbital Blowout FracturesOrbital Blowout FracturesClinical FindingsClinical Findings

► Periorbital Periorbital tenderness, tenderness, swelling, swelling, ecchymosis.ecchymosis.

► Enopthalmus or Enopthalmus or sunken eyes.sunken eyes.

► Impaired ocular Impaired ocular motility.motility.

► Infraorbital Infraorbital anesthesia.anesthesia.

► Step off deformityStep off deformity

Orbital Blowout FracturesOrbital Blowout FracturesImaging studiesImaging studies

► CT of orbitsCT of orbits Details the orbital Details the orbital

fracturefracture Excludes retrobulbar Excludes retrobulbar

hemorrhage.hemorrhage.

Zygoma FracturesZygoma Fractures

► 2nd most common facial bone fractures2nd most common facial bone fractures► The zygoma has 2 major components:The zygoma has 2 major components:

Zygomatic archZygomatic arch Zygomatic bodyZygomatic body

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

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

Zygoma Arch FracturesZygoma Arch Fractures

►Can fracture 2 to 3 places along the Can fracture 2 to 3 places along the archarch Lateral to each end of the archLateral to each end of the arch Fracture in the middle of the archFracture in the middle of the arch

►Patients usually present with pain on Patients usually present with pain on opening their mouth.opening their mouth.

Zygoma Arch FracturesZygoma Arch FracturesClinical FindingsClinical Findings

► Palpable bony defect Palpable bony defect over the archover the arch

► Depressed cheek with Depressed cheek with tendernesstenderness

► Pain in cheek and jaw Pain in cheek and jaw movementmovement

► Limited mandibular Limited mandibular movementmovement

Zygoma Arch FracturesZygoma Arch FracturesImaging Studies & TreatmentImaging Studies & Treatment► Radiographic Radiographic

imaging:imaging: Submental view Submental view

(bucket handle view)(bucket handle view) CT scanCT scan

Zygomatic Complex Zygomatic Complex FracturesFractures

► ZMC fx consist of ZMC fx consist of fractures through:fractures through: Zygomatic archZygomatic arch Zygomaticofrontal Zygomaticofrontal

suturesuture Inferior orbital rim Inferior orbital rim

and floorand floor

ZMC FracturesZMC FracturesClinical FeaturesClinical Features

► Clinical features:Clinical features: Periorbital edema Periorbital edema

and ecchymosisand ecchymosis Hypesthesia of the Hypesthesia of the

infraorbital nerveinfraorbital nerve Palpation may reveal Palpation may reveal

step offstep off Concomitant globe Concomitant globe

injuries are commoninjuries are common

Zygoma Tripod FracturesZygoma Tripod FracturesImaging StudiesImaging Studies

► Radiographic Radiographic imaging:imaging: Waters, Submental Waters, Submental

and Caldwell viewsand Caldwell views

► Coronal CT of the Coronal CT of the facial bones:facial bones: 3-D reconstruction3-D reconstruction

Maxillary FracturesMaxillary Fractures

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

is required .is required .►Patients often have significant Patients often have significant

multisystem trauma.multisystem trauma.►Classified as LeFort fractures.Classified as LeFort fractures.

Maxillary FracturesMaxillary FracturesLeFort ILeFort I

►Definition:Definition: Horizontal fracture of Horizontal fracture of

the maxilla at the the maxilla at the level of the nasal level of the nasal fossa.fossa.

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


► Clinical findings:Clinical findings: Facial edemaFacial edema Malocclusion of the Malocclusion of the

teethteeth Motion of the maxilla Motion of the maxilla

while the nasal while the nasal bridge remains bridge remains stablestable


► Radiographic Radiographic findings:findings: Fracture line which Fracture line which

involvesinvolves►Nasal apertureNasal aperture► Inferior maxillaInferior maxilla►Lateral wall of maxillaLateral wall of maxilla►Pterygoid platesPterygoid plates

►Maxillofacial CTMaxillofacial CT Axial and coronal Axial and coronal

cutscuts

Maxillary FracturesMaxillary FracturesLeFort IILeFort II

►Definition:Definition: Pyramidal fracturePyramidal fracture

►MaxillaMaxilla►Nasal bones Nasal bones ►Medial aspect of the Medial aspect of the

orbitsorbits


► Clinical findings:Clinical findings: Marked facial edemaMarked facial edema Nasal flatteningNasal flattening Traumatic Traumatic

telecanthustelecanthus Epistaxis or CSF Epistaxis or CSF

rhinorrhea rhinorrhea Movement of the Movement of the

upper jaw and the upper jaw and the nose. nose.


► Radiographic Radiographic imaging:imaging: Fracture involves:Fracture involves:

►Nasal bonesNasal bones►Medial orbitMedial orbit►Maxillary sinusMaxillary sinus►Frontal process of Frontal process of

the maxilla the maxilla

►Maxillofacial CTMaxillofacial CT

Maxillary FracturesMaxillary FracturesLeFort IIILeFort III

►Definition:Definition: Fractures through:Fractures through:

►MaxillaMaxilla►ZygomaZygoma►Nasal bonesNasal bones►Ethmoid bonesEthmoid bones►Base of the skullBase of the skull


► Clinical findings:Clinical findings: Dish faced deformityDish faced deformity Epistaxis and CSF Epistaxis and CSF

rhinorrhea rhinorrhea Motion of the Motion of the

maxilla, nasal bones maxilla, nasal bones and zygomaand zygoma

Severe airway Severe airway obstructionobstruction


► Radiographic Radiographic imaging:imaging: Fractures through:Fractures through:

►Zygomaticfrontal Zygomaticfrontal suturesuture

►ZygomaZygoma►Medial orbital wallMedial orbital wall►Nasal boneNasal bone

► CT Face and the CT Face and the HeadHead

Mandible FracturesMandible FracturesPathophysiologyPathophysiology

►Mandibular Mandibular fractures are the fractures are the third most common third most common facial fracture.facial fracture.

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

►Multiple fractures Multiple fractures are seen in greater are seen in greater then 50%.then 50%.

Mandible FracturesMandible FracturesClinical findingsClinical findings

► Mandibular pain.Mandibular pain.► Malocclusion of the Malocclusion of the

teethteeth► Separation of teeth Separation of teeth

with intraoral bleedingwith intraoral bleeding► Inability to fully open Inability to fully open

mouth.mouth.► Preauricular pain with Preauricular pain with

biting. biting. ► Positive tongue blade Positive tongue blade

test.test.

Mandible FracturesMandible Fractures► Radiographs:Radiographs:

Panoramic viewPanoramic view Mandible Series: PA, bilateral obliques, and a Mandible Series: PA, bilateral obliques, and a

Townes view (axial AP)Townes view (axial AP) Maxillofacial CTMaxillofacial CT

Mandibular DislocationMandibular Dislocation

► Causes of mandibular dislocation are:Causes of mandibular dislocation are: Blunt traumaBlunt trauma Excessive mouth openingExcessive mouth opening

► Risk factors:Risk factors: Weakness of the temporal mandibular ligamentWeakness of the temporal mandibular ligament Over stretched joint capsule Over stretched joint capsule Shallow articular eminenceShallow articular eminence Neurologic diseasesNeurologic diseases


► The mandible can The mandible can be dislocated:be dislocated: Anterior 70%Anterior 70% PosteriorPosterior LateralLateral Superior Superior

►Dislocations are Dislocations are mostly bilateral.mostly bilateral.


► Posterior dislocations:Posterior dislocations: Direct blow to the chinDirect blow to the chin Condylar head is pushed against the mastoidCondylar head is pushed against the mastoid

► Lateral dislocations:Lateral dislocations: Associated with a jaw fractureAssociated with a jaw fracture Condylar head is forced laterally and superiorlyCondylar head is forced laterally and superiorly

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


► Clinical features:Clinical features: Inability to close Inability to close

mouthmouth PainPain Facial swellingFacial swelling

► Physical exam:Physical exam: Palpable depressionPalpable depression Jaw will deviate awayJaw will deviate away Jaw displaced anteriorJaw displaced anterior


►Diagnosis:Diagnosis: History & Physical History & Physical

examexam X-raysX-rays CT CT


► Treatment:Treatment: Muscle relaxantMuscle relaxant AnalgesicAnalgesic Closed reduction in Closed reduction in

the emergency roomthe emergency room


►Disposition:Disposition: Avoid excessive mouth openingAvoid excessive mouth opening Soft dietSoft diet AnalgesicsAnalgesics Follow up Follow up

Maxillofacial Trauma Brief Overview. Physical Exam: some things to look for ► Inspection of the...

Documents

Transcript of Maxillofacial Trauma Brief Overview. Physical Exam: some things to look for ► Inspection of the...