Download 04. Features of the maxillofacial area (MFA) injuries

Features of the maxillofacial area
(MFA) injuries. Classification,
debridement of soft tissue wounds MFA.
Nongunshot damage of the lower and
upper jaws: Anatomy injury,
pathogenesis, classification, statistics,
symptoms, diagnosis, transportation
immobilization. Damage to the
zygomatic bone, nasal bones in
peacetime: classification, incidence,
clinical features, diagnosis and
treatment.
Maxillofacial trauma
Management of
traumatized patient
2
Organization of trauma services
triage decisions are crucial in
determining individual patients survival

Pre-hospital care (field triage)
Care delivered by fully trained paramedic in maintaining airway, controlling
cervical spine, securing intravenous and initiating fluid resuscitation

Hospital care (inter-hospital triage)
Senior medical staff organized team to ensure that medical resources are
deployed to maximum overall benefit

Mass casualty triage
3
Primary survey
Ⓐ Airway maintenance with cervical
control
spine
Ⓑ Breathing and ventilation
Ⓒ Circulation with hemorrhage control
Ⓓ Disability assessment of neurological status
Ⓔ Exposure and complete examination of the
patient
4
Airway

Satisfactory airway signifies the implication of
breathing and ventilation and cerebral function

Management of maxillofacial trauma is an
integral part in securing an unobstructed
airway

Immobilization in a natural position by a semirigid collar until damaged spine is excluded
5
Sequel of facial injury
Obstruction of airway
asphyxia
Cerebral hypoxia
Brain damage/ death
Is the patient fully conscious? And able to maintain adequate airway?
Semiconscious or unconscious patient rapidly suffocate because of inability
to cough and adopt a posture that held tongue forward
6
Breathing and ventilation

Chest injuries:
Pneumothorax, haemopneumothorax, flail segments,
reputure daiphram, cardiac tamponade
signs
Clinical
Deviated trachea
Absence of breath
sounds
Dullness to percussion
Paradoxical movements
Hyper-response with
a large pneumothorax
Muffled heart sounds
Radiographical
Loss of lung marking
Deviation of trachea
Raised hemi-diaphragm
Fluid levels
Fracture of ribs
7
Circulation
Circulatory collapse leads to low blood pressure,
increasing pulse rate and diminished capillary
filling at the periphery
Patient resuscitation
Restoration of cardio-respiratory function
Shock management
Replacement of lost fluid
8
Glasgow coma scale (GCS)
(Teasdale and Jennett, 1974)
Eye
opening
Motor
response
Verbal
response
Spontaneous 4 Move to
command
6 Converse
5
To speech
3 Localizes to
pain
5 Confused
4
To pain
2 Withdraw
from pain
4 Gibberish
3
none
1 flexes
3 grunts
2
Extends
2
none
1
none
Score 8 or less indicates poor prognosis, moderate head
injury between 9-12 and mild refereed to 13-15
1
9
Exposure
All trauma patient must be fully exposed in a
warm environment to disclose any other hidden
injuries
When the airway is adequately secured the second
survey of the whole body is to be carried out for:




Accurate diagnosis
Maintenance of a stable state
Determination of priorities in treatment
Appropriate specialist referral
10
Head injury
Many of facial injury patients sustain head
injury in particular the mid face injuries

Open

Closed
it is ranged from Mild concussion to brain death
11
Signs and symptoms of head injury





Loss of conscious
OR
History of loss of conscious
History of vomiting
Change in pulse rate, blood pressure and pupil reaction to
light in association with increased intracranial pressure
Assessment of head injury (behavioral responses “motor
and verbal responses” and eye opening)

Skull fracture
 Skull base fracture (battle’s sign)
 Temporal/ frontal bone fracture
 Naso-orbital ethmoidal fracture
12
slow reaction and fixation of dilated pupil denotes
a rise in intra-cranial pressure
Rise in intercranial pressure as a result of acute
subdural or extradural hemorrhage deteriorate the
patient’s neurological status
Apparently stable patient with suspicion of head injury must be
monitored at intervals up to one hour for 24 hour after the
trauma
13
Hemorrhage
Acute bleeding may lead to hemorrhagic shock and
circulatory collapse

Abdominal and pelvis injury; liver and internal
organs injury (peritonism)

Fracture of the extremities (femur)
14
Preliminary treatment in complex
facial injury

Soft tissue laceration (8 hours of injury with no delay
beyond 24 hours)

Support of the bone fragments

Injury to the eye
As a result of trauma, 1.6 million are blind, 2.3 million are
suffering serious bilateral visual impairment and 19 million with
unilateral loss of sight (Macewen 1999)



Ocular damage
Reduction in visual acuity
Eyelid injury
15
Prevention of infection
Fractures of jaw involving teeth bearing areas
are compound in nature and midface fracture
may go high, leading to CSF leaks
(rhinorrhoea, otorrhoea) and risk of meningitis,
and in case of perforation of cartilaginous
auditory canal

Diagnosis:
Laboratory investigation, CT and MRI scan
 Management:
–
–
–
–
–
Dressing of external wounds
Closure of open wounds
Reposition and immobilization of the fractures
Repair of the dura matter
Antibacterial prophylaxis (as part of the general management (Eljamal, 1993)
16
Control of pain
Displaced fracture may cause severe pain but
strong analgesic ( Morphine and its derivatives)
must be avoided as they depress cough reflex,
constrict pupils as they may mask the signs of
increasing intracranial pressure
Management:
☞ Non-steroidal anti-inflammatory drugs can be prescribed
(Diclofenac acid)
☞ Reduction of fracture
☞ sedation
17
In patient care

Necessary medications

Diet (fluid, semi-fluid and solid food) intake
and output (fluid balance chart)

Hygiene and physiotherapy

Proper timing for surgical intervention
18
Anatomy
Anatomy
Physical 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
Physical 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.
Physical 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.
Physical Examination

Check visual acuity.
 Check pupils for roundness and reactivity.
 Examine the eyelids for lacerations.
 Test extra ocular muscles.
 Palpate around the entire orbits..
Physical 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.
Physical Examination

Examine and palpate the exterior ears.
 Examine the ear canals.
 Check nuero distributions of the
supraorbital, infraorbital, inferior alveolar
and mental nerves.
Frontal Sinus/ Bone Fractures
Pathophysiology

Results from a direct blow to the frontal
bone with blunt object.
 Associated with:
– Intracranial injuries
– Injuries to the orbital roof
– Dural tears
Frontal Sinus/ Bone Fractures
Clinical Findings

Disruption or
crepitance orbital rim
 Subcutaneous
emphysema
 Associated with a
laceration
Frontal Sinus/ Bone Fractures
Diagnosis

Radiographs:
– Facial views should
include Waters,
Caldwell and lateral
projections.
– Caldwell view best
evaluates the anterior
wall fractures.
Frontal Sinus/ Bone Fractures
Diagnosis

CT Head with bone
windows:
– Frontal sinus fractures.
– Orbital rim and
nasoethmoidal
fractures.
– R/O brain injuries or
intracranial bleeds.
Frontal Sinus/ Bone Fractures
Treatment

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.
Frontal Sinus/ Bone Fractures
Complications

Associated with intracranial injuries:
– Orbital roof fractures.
– Dural tears.
– Mucopyocoele.
– Epidural empyema.
– CSF leaks.
– Meningitis.
Naso-Ethmoidal-Orbital
Fracture




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.
Naso-Ethmoidal-Orbital
Fracture

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.
Naso-Ethmoidal-Orbital
Fracture

Imaging studies:
– Plain radiographs are insensitive.
– CT of the face with coronal cuts through the
medial orbits.

Treatment:
– Maxillofacial consultation.
– ? Antibiotic
Nasal Fractures

Most common of all facial fractures.
 Injuries may occur to other surrounding
bony structures.
 3 types:
– Depressed
– Laterally displaced
– Nondisplaced
Nasal Fractures

Ask the patient:
– “Have you ever broken your nose before?”
– “How does your nose look to you?”
– “Are you having trouble breathing?”
Nasal Fractures

Clinical findings:
– Nasal deformity
– Edema and tenderness
– Epistaxis
– Crepitus and mobility
Nasal Fractures

Diagnosis:
– History and physical
exam.
– Lateral or Waters view
to confirm your
diagnosis.
Nasal Fractures

Treatment:
– Control epistaxis.
– Drain septal
hematomas.
– Refer patients to ENT
as outpatient.
Orbital Blowout Fractures

Blow out fractures are the most common.
 Occur when the the globe sustains a direct
blunt force
 2 mechanisms of injury:
– Blunt trauma to the globe
– Direct blow to the infraorbital rim
Orbital Blowout Fractures
Clinical Findings





Periorbital tenderness,
swelling, ecchymosis.
Enopthalmus or
sunken eyes.
Impaired ocular
motility.
Infraorbital anesthesia.
Step off deformity
Orbital Blowout Fractures
Imaging studies

Radiographs:
– Hanging tear drop sign
– Open bomb bay door
– Air fluid levels
– Orbital emphysema
Orbital Blowout Fractures
Imaging studies

CT of orbits
– Details the orbital
fracture
– Excludes retrobulbar
hemorrhage.

CT Head
– R/o intracranial
injuries
Orbital Blowout Fractures
Treatment

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.
Zygoma 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)
Zygoma 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.
Zygoma Arch Fractures
Clinical Findings

Palpable bony defect
over the arch
 Depressed cheek with
tenderness
 Pain in cheek and jaw
movement
 Limited mandibular
movement
Zygoma Arch Fractures
Imaging Studies & Treatment

Radiographic imaging:
– Submental view
(bucket handle view)

Treatment:
– Consult maxillofacial
surgeon
– Ice and analgesia
– Possible open elevation
Zygoma Tripod Fractures

Tripod fractures
consist of fractures
through:
– Zygomatic arch
– Zygomaticofrontal
suture
– Inferior orbital rim and
floor
Zygoma Tripod Fractures
Clinical Features

Clinical features:
– Periorbital edema and
ecchymosis
– Hypesthesia of the
infraorbital nerve
– Palpation may reveal
step off
– Concomitant globe
injuries are common
Zygoma Tripod Fractures
Imaging Studies

Radiographic imaging:
– Waters, Submental and
Caldwell views

Coronal CT of the
facial bones:
– 3-D reconstruction
Zygoma Tripod Fractures
Treatment

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.
Maxillary Fractures

High energy injuries.
 Impact 100 times the force of gravity is
required .
 Patients often have significant multisystem
trauma.
 Classified as LeFort fractures.
Maxillary Fractures
LeFort 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.
Maxillary Fractures
LeFort I

Clinical findings:
– Facial edema
– Malocclusion of the
teeth
– Motion of the maxilla
while the nasal bridge
remains stable
Maxillary Fractures
LeFort 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
Maxillary Fractures
LeFort II

Definition:
– Pyramidal fracture



Maxilla
Nasal bones
Medial aspect of the
orbits
Maxillary Fractures
LeFort II

Clinical findings:
– Marked facial edema
– Nasal flattening
– Traumatic telecanthus
– Epistaxis or CSF
rhinorrhea
– Movement of the upper
jaw and the nose.
Maxillary Fractures
LeFort II

Radiographic imaging:
– Fracture involves:





Nasal bones
Medial orbit
Maxillary sinus
Frontal process of the
maxilla
CT of the face and
head
Maxillary Fractures
LeFort III

Definition:
– Fractures through:





Maxilla
Zygoma
Nasal bones
Ethmoid bones
Base of the skull
Maxillary Fractures
LeFort III

Clinical findings:
– Dish faced deformity
– Epistaxis and CSF
rhinorrhea
– Motion of the maxilla,
nasal bones and
zygoma
– Severe airway
obstruction
Maxillary Fractures
LeFort III

Radiographic imaging:
– Fractures through:





Zygomaticfrontal suture
Zygoma
Medial orbital wall
Nasal bone
CT Face and the Head
Maxillary Fractures
Treatment

Secure and airway
 Control Bleeding
 Head elevation 40-60 degrees
 Consult with maxillofacial surgeon
 Consider antibiotics
 Admission
Mandible Fractures
Pathophysiology




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%.
Mandible Fractures
Clinical 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.
Mandible Fractures

Radiographs:
– Panoramic view
– Plain view: PA, Lateral and a Townes view
Mandibular Fractures
Treatment

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.
Mandibular 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
Mandibular Dislocation

The mandible can be
dislocated:
– Anterior 70%
– Posterior
– Lateral
– Superior

Dislocations are
mostly bilateral.
Mandibular 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
Mandibular Dislocation

Clinical features:
– Inability to close
mouth
– Pain
– Facial swelling

Physical exam:
– Palpable depression
– Jaw will deviate away
– Jaw displaced anterior
Mandibular Dislocation

Diagnosis:
– History & Physical
exam
– X-rays
– CT
Mandibular Dislocation

Treatment:
– Muscle relaxant
– Analgesic
– Closed reduction in the
emergency room
Mandibular Dislocation

Treatment:
– Oral surgeon consultation:
 Open dislocations
 Superior, posterior or lateral dislocations
 Non-reducible dislocations
 Dislocations associated with fractures
Mandibular Dislocation

Disposition:
– Avoid excessive mouth opening
– Soft diet
– Analgesics
– Oral surgery follow up
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