maxillofacial trauma
TRANSCRIPT
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Maxillofacial Trauma Maxillofacial Trauma
By
Daniel Cerbone D.O.
St. Barnabas Hospital
Emergency Department
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PathophysiologyPathophysiology
Maxillofacial fractures result from either blunt or penetrating trauma.
Penetrating injuries are more common in city hospitals.– Midfacial and zygomatic injuries.
Blunt injuries are more frequently seen in community hospitals.– Nose and mandibular injuries.
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PathophysiologyPathophysiology
High Impact:– Supraorbital rim – 200 G– Symphysis of the Mandible –100 G– Frontal – 100 G– Angle of the mandible – 70 G
Low Impact:– Zygoma – 50 G– Nasal bone – 30 G
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EtiologyEtiology
@60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise.– 20-50% concurrent brain injury.– 1-4% cervical spine injuries.– Blindness occurs in 0.5-3%
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EtiologyEtiology
25% of women with facial trauma are victims of domestic violence.– Increases to 30% if an orbital wall fx is present.
25% of patients with severe facial trauma will develop Post Traumatic Stress Disorder
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AnatomyAnatomy
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AnatomyAnatomy
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Emergency ManagementEmergency ManagementAirway ControlAirway Control
Control airway:– Chin lift.– Jaw thrust.– Oropharyngeal suctioning.– Manually move the tongue forward.– Maintain cervical immobilization
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Emergency ManagementEmergency ManagementIntubation ConsiderationsIntubation Considerations
Avoid nasotracheal intubation:– Nasocranial intubation– Nasal hemorrhage
Avoid Rapid Sequence Intubation:– Failure to intubate or ventilate.
Consider an awake intubation.Sedate with benzodiazepines.
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Emergency ManagementEmergency ManagementIntubation ConsiderationsIntubation Considerations
Consider fiberoptic intubation if available. Alternatives include percutaneous
transtracheal ventilation and retrograde intubation.
Be prepared for cricothyroidotomy.
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Emergency ManagementEmergency ManagementHemorrhage ControlHemorrhage Control
Maxillofacial bleeding:– Direct pressure.– Avoid blind clamping in wounds.
Nasal bleeding:– Direct pressure.– Anterior and posterior packing.
Pharyngeal bleeding:– Packing of the pharynx around ET tube.
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HistoryHistory
Obtain a history from the patient, witnesses and or EMS.
AMPLE historySpecific Questions:
– Was there LOC? If so, how long?– How is your vision?– Hearing problems?
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HistoryHistory
Specific Questions:– Is there pain with eye movement?– Are there areas of numbness or tingling on your
face?– Is the patient able to bite down without any
pain?– Is there pain with moving the jaw?
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Physical ExaminationPhysical Examination
Inspection of the face for asymmetry.Inspect open wounds for foreign bodies.Palpate the entire face.
– Supraorbital and Infraorbital rim– Zygomatic-frontal suture– Zygomatic arches
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Physical ExaminationPhysical Examination
Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge.
Inspect nasal septum for septal hematoma, CSF or blood.
Palpate nose for crepitus, deformity and subcutaneous air.
Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone.
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Physical ExaminationPhysical Examination
Check facial stability. Inspect the teeth for malocclusions, bleeding and
step-off. Intraoral examination:
– Manipulation of each tooth.– Check for lacerations.– Stress the mandible.– Tongue blade test.
Palpate the mandible for tenderness, swelling and step-off.
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Physical ExaminationPhysical Examination
Check visual acuity.Check pupils for roundness and reactivity.Examine the eyelids for lacerations.Test extra ocular muscles.Palpate around the entire orbits..
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Physical ExaminationPhysical Examination
Examine the cornea for abrasions and lacerations.
Examine the anterior chamber for blood or hyphema.
Perform fundoscopic exam and examine the posterior chamber and the retina.
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Physical ExaminationPhysical Examination
Examine and palpate the exterior ears.Examine the ear canals.Check nuero distributions of the
supraorbital, infraorbital, inferior alveolar and mental nerves.
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Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesPathophysiologyPathophysiology
Results from a direct blow to the frontal bone with blunt object.
Associated with:– Intracranial injuries– Injuries to the orbital roof– Dural tears
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Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesClinical FindingsClinical Findings
Disruption or crepitance orbital rim
Subcutaneous emphysema
Associated with a laceration
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Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesDiagnosisDiagnosis
Radiographs:– Facial views should
include Waters, Caldwell and lateral projections.
– Caldwell view best evaluates the anterior wall fractures.
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Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesDiagnosisDiagnosis
CT Head with bone windows:– Frontal sinus fractures. – Orbital rim and
nasoethmoidal fractures.
– R/O brain injuries or intracranial bleeds.
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Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesTreatmentTreatment
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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Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesComplicationsComplications
Associated with intracranial injuries:– Orbital roof fractures.– Dural tears.– Mucopyocoele.– Epidural empyema.– CSF leaks.– Meningitis.
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Naso-Ethmoidal-Orbital Naso-Ethmoidal-Orbital FractureFracture
Fractures that extend into the nose through the ethmoid bones.
Associated with lacrimal disruption and dural tears.
Suspect if there is trauma to the nose or medial orbit.
Patients complain of pain on eye movement.
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Naso-Ethmoidal-Orbital Naso-Ethmoidal-Orbital FractureFracture
Clinical findings:– Flattened nasal bridge or a saddle-shaped
deformity of the nose.– Widening of the nasal bridge (telecanthus)– CSF rhinorrhea or epistaxis.– Tenderness, crepitus, and mobility of the nasal
complex.– Intranasal palpation reveals movement of the
medial canthus.
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Naso-Ethmoidal-Orbital Naso-Ethmoidal-Orbital FractureFracture
Imaging studies:– Plain radiographs are insensitive.– CT of the face with coronal cuts through the
medial orbits.
Treatment:– Maxillofacial consultation.– ? Antibiotic
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Nasal FracturesNasal Fractures
Most common of all facial fractures.Injuries may occur to other surrounding
bony structures.3 types:
– Depressed– Laterally displaced– Nondisplaced
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Nasal FracturesNasal Fractures
Ask the patient:– “Have you ever broken your nose before?”– “How does your nose look to you?”– “Are you having trouble breathing?”
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Nasal FracturesNasal Fractures
Clinical findings:– Nasal deformity– Edema and tenderness– Epistaxis– Crepitus and mobility
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Nasal FracturesNasal Fractures
Diagnosis:– History and physical
exam.– Lateral or Waters view
to confirm your diagnosis.
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Nasal FracturesNasal Fractures
Treatment:– Control epistaxis.– Drain septal
hematomas.– Refer patients to ENT
as outpatient.
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Orbital Blowout FracturesOrbital Blowout Fractures
Blow out fractures are the most common.Occur when the the globe sustains a direct
blunt force2 mechanisms of injury:
– Blunt trauma to the globe– Direct blow to the infraorbital rim
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Orbital Blowout FracturesOrbital Blowout FracturesClinical FindingsClinical Findings
Periorbital tenderness, swelling, ecchymosis.
Enopthalmus or sunken eyes.
Impaired ocular motility.
Infraorbital anesthesia. Step off deformity
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Orbital Blowout FracturesOrbital Blowout FracturesImaging studiesImaging studies
Radiographs:– Hanging tear drop sign– Open bomb bay door– Air fluid levels– Orbital emphysema
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Orbital Blowout FracturesOrbital Blowout FracturesImaging studiesImaging studies
CT of orbits– Details the orbital
fracture– Excludes retrobulbar
hemorrhage.
CT Head– R/o intracranial
injuries
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Orbital Blowout FracturesOrbital Blowout FracturesTreatmentTreatment
Blow out fractures without eye injury do not require admission– Maxillofacial and ophthalmology consultation– Tetanus– Decongestants for 3 days– Prophylactic antibiotics– Avoid valsalva or nose blowing
Patients with serious eye injuries should be admitted to ophthalmology service for further care.
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Zygoma FracturesZygoma Fractures
The zygoma has 2 major components:– Zygomatic arch– Zygomatic body
Blunt trauma most common cause.Two types of fractures can occur:
– Arch fracture (most common)– Tripod fracture (most serious)
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Zygoma Arch FracturesZygoma Arch Fractures
Can fracture 2 to 3 places along the arch– Lateral to each end of the arch– Fracture in the middle of the arch
Patients usually present with pain on opening their mouth.
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Zygoma Arch FracturesZygoma Arch FracturesClinical FindingsClinical Findings
Palpable bony defect over the arch
Depressed cheek with tenderness
Pain in cheek and jaw movement
Limited mandibular movement
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Zygoma Arch FracturesZygoma Arch FracturesImaging Studies & TreatmentImaging Studies & Treatment
Radiographic imaging:– Submental view
(bucket handle view)
Treatment:– Consult maxillofacial
surgeon– Ice and analgesia– Possible open elevation
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Zygoma Tripod FracturesZygoma Tripod Fractures
Tripod fractures consist of fractures through:– Zygomatic arch– Zygomaticofrontal
suture– Inferior orbital rim and
floor
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Zygoma Tripod FracturesZygoma Tripod FracturesClinical FeaturesClinical Features
Clinical features:– Periorbital edema and
ecchymosis– Hypesthesia of the
infraorbital nerve– Palpation may reveal
step off– Concomitant globe
injuries are common
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Zygoma Tripod FracturesZygoma Tripod FracturesImaging StudiesImaging Studies
Radiographic imaging:– Waters, Submental and
Caldwell views
Coronal CT of the facial bones:– 3-D reconstruction
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Zygoma Tripod FracturesZygoma Tripod FracturesTreatmentTreatment
Nondisplaced fractures without eye involvement– Ice and analgesics– Delayed operative consideration 5-7 days– Decongestants – Broad spectrum antibiotics – Tetanus
Displaced tripod fractures usually require admission for open reduction and internal fixation.
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Maxillary FracturesMaxillary Fractures
High energy injuries.Impact 100 times the force of gravity is
required .Patients often have significant multisystem
trauma.Classified as LeFort fractures.
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Maxillary FracturesMaxillary FracturesLeFort ILeFort I
Definition:– Horizontal fracture of
the maxilla at the level of the nasal fossa.
– Allows motion of the maxilla while the nasal bridge remains stable.
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Maxillary FracturesMaxillary FracturesLeFort ILeFort I
Clinical findings:– Facial edema– Malocclusion of the
teeth– Motion of the maxilla
while the nasal bridge remains stable
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Maxillary FracturesMaxillary FracturesLeFort ILeFort I
Radiographic findings:– Fracture line which
involves Nasal aperture Inferior maxilla Lateral wall of maxilla
CT of the face and head – coronal cuts– 3-D reconstruction
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Maxillary FracturesMaxillary FracturesLeFort IILeFort II
Definition:– Pyramidal fracture
Maxilla Nasal bones Medial aspect of the
orbits
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Maxillary FracturesMaxillary FracturesLeFort IILeFort II
Clinical findings:– Marked facial edema– Nasal flattening– Traumatic telecanthus– Epistaxis or CSF
rhinorrhea – Movement of the upper
jaw and the nose.
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Maxillary FracturesMaxillary FracturesLeFort IILeFort II
Radiographic imaging:– Fracture involves:
Nasal bones Medial orbit Maxillary sinus Frontal process of the
maxilla
CT of the face and head
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Maxillary FracturesMaxillary FracturesLeFort IIILeFort III
Definition:– Fractures through:
Maxilla Zygoma Nasal bones Ethmoid bones Base of the skull
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Maxillary FracturesMaxillary FracturesLeFort IIILeFort III
Clinical findings:– Dish faced deformity– Epistaxis and CSF
rhinorrhea – Motion of the maxilla,
nasal bones and zygoma
– Severe airway obstruction
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Maxillary FracturesMaxillary FracturesLeFort IIILeFort III
Radiographic imaging:– Fractures through:
Zygomaticfrontal suture Zygoma Medial orbital wall Nasal bone
CT Face and the Head
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Maxillary FracturesMaxillary FracturesTreatmentTreatment
Secure and airwayControl BleedingHead elevation 40-60 degreesConsult with maxillofacial surgeonConsider antibioticsAdmission
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Mandible FracturesMandible FracturesPathophysiologyPathophysiology
Mandibular fractures are the third most common facial fracture.
Assaults and falls on the chin account for most of the injuries.
Multiple fractures are seen in greater then 50%.
Associated C-spine injuries – 0.2-6%.
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Mandible FracturesMandible FracturesClinical findingsClinical findings
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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Mandible FracturesMandible Fractures
Radiographs:– Panoramic view– Plain view: PA, Lateral and a Townes view
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Mandibular FracturesMandibular FracturesTreatmentTreatment
Nondisplaced fractures:– Analgesics– Soft diet– oral surgery referral in 1-2 days
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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Mandibular DislocationMandibular Dislocation
Causes of mandibular dislocation are:– Blunt trauma– Excessive mouth opening
Risk factors:– Weakness of the temporal mandibular ligament– Over stretched joint capsule – Shallow articular eminence– Neurologic diseases
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Mandibular DislocationMandibular Dislocation
The mandible can be dislocated:– Anterior 70%– Posterior– Lateral– Superior
Dislocations are mostly bilateral.
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Mandibular DislocationMandibular Dislocation
Posterior dislocations:– Direct blow to the chin– Condylar head is pushed against the mastoid
Lateral dislocations:– Associated with a jaw fracture– Condylar head is forced laterally and superiorly
Superior dislocations:– Blow to a partially open mouth– Condylar head is force upward
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Mandibular DislocationMandibular Dislocation
Clinical features:– Inability to close
mouth– Pain– Facial swelling
Physical exam:– Palpable depression– Jaw will deviate away– Jaw displaced anterior
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Mandibular DislocationMandibular Dislocation
Diagnosis:– History & Physical
exam– X-rays– CT
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Mandibular DislocationMandibular Dislocation
Treatment:– Muscle relaxant– Analgesic– Closed reduction in the
emergency room
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Mandibular DislocationMandibular Dislocation
Treatment:– Oral surgeon consultation:
Open dislocations Superior, posterior or lateral dislocations Non-reducible dislocations Dislocations associated with fractures
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Mandibular DislocationMandibular Dislocation
Disposition:– Avoid excessive mouth opening– Soft diet– Analgesics– Oral surgery follow up
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