intern’s hour
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Intern’s Hour. Maxillofacial Trauma Preceptor: Dr. Germar BLOCK R. The Case. 24-year-old male who sustained traumatic injuries during a soccer game DOI: 3/18/2010 TOI: 7 AM POI: soccer field MOI: - PowerPoint PPT PresentationTRANSCRIPT
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Intern’s Hour
Maxillofacial TraumaPreceptor: Dr. Germar
BLOCK R
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The Case
24-year-old male who sustained traumatic injuries during a soccer game
DOI: 3/18/2010 TOI: 7 AM POI: soccer field MOI: Few hours PTC, the patient,
a soccer goalkeeper, attempted to recover a loose ball when he was struck in the face by an opponent’s knee.After contact, the patient fell to the ground on his left side in a side-lying position.
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Review of Systems
(-) LOC (-) seizure (+) headache (+) dizziness (-) vomiting (-) rhinorrhea/
epistaxis (-) otorrhea
(-) dyspnea (-) chest pain (-) abdominal pain (-) urinary and
bowel changes
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Physical Examination
VS: BP 130/80, HR 86, RR 20, afeb
HEAD and NECK: (+) R periorbital edema
with subconjunctival hemorrhage, OD
R facial swelling and tenderness
(+) crepitus on R maxillary area
(+) upper lip laceration (-) malocclusion, able to
open mouth to 4 fingerbreaths
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Physical Examination
HEART AP, DHS, NRRR, apex beat @ 5th ICS
LMCL, (-) murmurCHEST and LUNGS
ECE, CBS, (-) crackles/ wheezesABDOMEN
Soft, flat abdomen, NABS, (-) tendernessEXTREMITIES
PNB, FEP, (-) cyanosi/ edema
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Physical Examination
NEURO GCS 15 (E4V5M6), oriented to 3 spheres CN intact Motor strength 5/5 on all extremities (-) sensory deficit DTRs 2+, (-) Babinski Supple neck
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Assessment
Multiple Injuries 2⁰ to --- 1. R periorbital contusion with
subconjunctival hemorrhage of the R eye 2. t/c R maxillary fracture r/o intracranial injury
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Course
Upon arrival at the ER, A: with the athlete in the supine position, an
attempt to open the airway using a modified jaw-thrust maneuver was performed.
B: the breathing can be compromised as a result of blood from ongoing facial bleeding. After blood was quickly cleared from the face, the source of bleeding was identified in the upper lip, which had sustained a complete through-and-through laceration. Direct pressure was immediately applied.
C: blood pressure was noted to be normal, cervical spine was secured
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Diagnostics
CBC Blood type PT/PTTNa, K, Cl, BUN, Crea
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Diagnostics
Towne’s, Water’s, SMV radiographs of the chest, cervical
spine The radiographs revealed no evidence of
vertebral fracture or pulmonary diseasecomputed tomography (CT) scans of
the brain and face
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CT scan
The CT scans identified fractures of the anterior, posterior, and medial walls of the right maxillary sinus. A small pocket of air was identified in the right infratemporal fossa, suggesting an occult fracture of the lateral wall of the right maxillary sinus. The initial facial CT scan also suggested a fracture of the floor of the right orbit.
The cranial CT showed no evidence of skull fracture or intracranial injury.
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Final Diagnosis
Multiple Injuries 2⁰ to --- 1. R periorbital contusion with
subconjunctival hemorrhage of the R eye 2. R maxillary fracture
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1. Fractures of the Nasal Pyramid
2. Fractures of the Central Midface
Le Fort Fractures
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3. Fractures of the Lateral Midface
4. Fractures of the Frontal bone
5. Fractures of the Anterior Skull Base
Escher Classification
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6. Fractures or dislocation of the mandible
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Sports Vehicular Accidents Mauling
Women – consider the possibility of domestic violence
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Patients with severe facial trauma: multisystem trauma potential for airway compromise concurrent brain injury cervical spine injuries blindness
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Primary Survey Airway Breathing Circulation
Secondary Survey
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Airway: Chin lift. Jaw thrust. Oropharyngeal suctioning Manually move the tongue forward
Maintain cervical immobilization
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Avoid nasotracheal intubation Adverse effects:▪ Nasocranial intubation▪ Nasal hemorrhage
cricothyroidotomy
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Circulation:
Direct pressure
Anterior and posterior nasal packing
Packing of the pharynx around ET tube
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Place, Time, Date, Mechanism of injury
Detailed description of the circumstances surrounding the injury
Allergies, other medical problems, medications, tetanus immunizations
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Questions: Was there LOC, nausea/vomiting, headache? (Head
Trauma related questions) How is your vision? Hearing problems? Is there pain with eye movement? Are there areas of numbness or tingling on your
face? Able to bite down without any pain? Is there pain with moving the jaw?
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Inspection Open wounds for foreign
bodies
Facial asymmetry
Nose for deviation, widening of bridge
Nasal septum for septal hematoma, CSF or blood
Ears for blood or CSF
Malocclusion
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Raccoon eyes
Inspection
Battle’s sign
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Inspection
Otorrhea, Rhinorrhea
Halo Sign
Not sensitive or specific but can be used as a preliminary test for CSF in blood
Dipstick
Beta transferrin
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Palpation Palpate the entire face.
Supraorbital and Infraorbital rim Zygomatic-frontal suture Zygomatic arches
Nose - crepitus, deformity and subcutaneous air Zygoma along its arch and its articulations with
the maxilla, frontal and temporal bone Mandible for tenderness, swelling
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Intraoral examination: Inspect the teeth for malocclusions, bleeding
Manipulation of each tooth
Check for lacerations
Mandibular movements
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Ophthalmologic exam
Visual acuity Pupils for shape and
reactivity Eyelids for lacerations Extra ocular muscles Palpate around the
orbits
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Examine and palpate the exterior ears
Otoscopic examination Look for lacerations TM rupture
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Plain films Confirm suspected clinical diagnosis Determine extent of injury Document fractures
CT scan
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ATS, TeAna Thorough evaluation of all wounds All foreign bodies must be removed Debridement Suturing of lacerations as needed Minimize scarring Antibiotics
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Most common bone injury in the face
Open or closed
Signs Depression or
displacement of nasal bones
Edema of nose Epistaxis Fracture of septal
cartilage with displacement or mobility
Crepitus on palpation
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All nasal injuries should be evaluated for septal hematoma
Untreated- result in septal necrosis and saddle nose deformity
Can become infected- result in a septal abscess
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Radiographs: Lateral projection
Treatment: Surgical
After reduction, nasal cavities should be packed – “internal splinting”
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Le Fort’s classification Le Fort I (transverse maxillary) Le Fort II (pyramidal) Le Fort III (craniofacial dysjunction)
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Low transverse fracture of maxilla involving palate
Facial edema Mobility of hard
palate and upper teeth
Malocclusion
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Pyramidal fracture with detachment of maxilla
Facial edema Epistaxis Bilateral
periorbital edema and ecchymosis
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Complete disruption of attachments of facial skeleton to cranium
Movement of all facial bones in relation to the cranial base with manipulation of the teeth and hard palate
Open patient’s mouth and grasp the maxilla arch Place the other hand on the forehead Gently move back and forth, up and down - check for movement of maxilla
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Massive edema with facial elongation, flattening – “Dish faced deformity”
Epistaxis and CSF rhinorrhea
Motion of the maxilla, nasal bones and zygoma
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Open reduction and intermaxillary fixation should be performed to establish correct occlusion
Followed by rigid fixation at the piriform rims and zygomaticomaxillary buttress.
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The zygoma has 2 major components: Zygomatic arch Zygomatic body
Two types of fractures can occur: Isolated Arch fracture -most common Tripod fracture - most serious
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Palpable bony defect over the arch
Flattening of the cheek
Pain in cheek and jaw movement
Limited mandibular movement
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Radiographic imaging: Submental view
“bucket handle view”
- Arches may not be seen in usual views (anterior, lateral)
Treatment: Symptomatic -
surgical
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Tripod fractures consist of fractures through: Zygomatic arch Zygomaticofrontal
suture Inferior orbital rim
and floor Symptoms
Periorbital edema Sensory
disturbances along the infraorbital nerve
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WatersCaldwellSubmental Coronal CT
Treatment: Symptomatic -
surgical
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Isolated fracture of the orbital floor with partial herniation of orbital contents
Facial asymmetry
Enophthalmos
Diplopia on upward gaze- impingement of inf. Rectus
Check for sensory disturbances – cheek, upper lip, lateral nasal wall
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CT scan
Management: Indicated for displaced fractures or for
symptomatic fractures
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Uncommon Depression of
anterior table of frontal sinus
Intracranial injuries Dural tears EpistaxisCSF rhinorrhea (disruption of
posterior table of frontal sinus with dural rupture)
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Radiographs: Facial views should
include: ▪ Waters ▪ Caldwell ▪ lateral projections
Caldwell view best evaluates the anterior wall fractures
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Cranial CT with bone window Frontal sinus
fractures. Orbital rim and
nasoethmoidal fractures
R/O brain injuries or intracranial bleeds
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Patients with depressed skull fractures or with posterior wall involvement. ENT or nuerosurgery consultation. Admission. IV antibiotics. Tetanus.
Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.
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Associated with intracranial injuries Orbital roof fractures Dural tears Mucopyocoele Epidural empyema CSF leaks Meningitis
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2nd most commonly fractured facial bone
Signs and symptoms Malocclusion of teeth Tooth mobility Intraoral lacerations Pain on mastication Bone deformity
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Mandibular pain
Malocclusion of the teeth
Separation of teeth with intraoral bleeding
Inability to fully open mouth
Preauricular pain with biting
Positive tongue blade test
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Radiographs: Panorex Plain view: PA, Lateral and a Townes view
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Treatment: Nondisplaced fractures:
Analgesics Soft diet Dent/ORL surgery referral
Displaced fractures, open fractures and fractures with associated dental trauma Urgent oral surgery consultation
All fractures should be treated with antibiotics and tetanus prophylaxis.
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PLAN
AntibioticsPain managementSuture the upper lip laceration.The facial fractures are nondisplaced
and do not require surgery. These facial fractures should be followed for evidence of healing.
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