PowerPoint Maxillofacial Trauma English

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

Philadelphia, PA USA

[email protected]

Maxillofacial Trauma

mailto:[email protected]

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


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

periorbital, subconjunctival


• Hemorrhage or airway obstruction may require emergent surgery

• Treatment can often be delayed till edema decreased


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


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 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


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


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


• 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


• 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

Documents

PowerPoint Maxillofacial Trauma English