PowerPoint Maxillofacial Trauma English
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Transcript of PowerPoint Maxillofacial Trauma English
Joe Lex, MD, FACEP, FAAEMTemple University School of Medicine
Philadelphia, PA USA
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
• 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
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
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)
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