Download Facial fractures

FACIAL FRACTURES
ETIOLOGY OF FACIAL TRAUMA
MVA
Interpersonal violence
ASSOCIATED INJURIES
Cervical spine injury 1-4 %
Regional trauma to the head LOC 55%
Intracranial damage 5 %
Skull base fractures
CSF leak
Carotid artery injury
Ocular trauma (25-29%)
Blindness (1-6%)
INITIAL MANGEMENT
1. Rule out limb or life threatening injuries
2. Stabilize the patient
3. AIRWAY
4. ADEQUATE VENTILATION
5. CONTROL HAEMORRHAGE
6. MANAGE NEUROSURGICAL, THORACIC AND ABDOMINAL
TRAUMA
SPECIFIC PROBLEMS
1. AIRWAY
a. Intubate, but may need urgent tracheostomy
2. HAEMORRHAGE
a. Analgesia
b. Resuscitation – transfuse
c. Intubate or tracheostomy
d. Oral-nasal packing
e. Theatre to reduce fractures
3. OCULAR INJURY
a. Early opthamology consult
b. steroids
c. Orbital decompression/lateral canthotomy
4. CSF RHINORRHEA
a. Neurology consultation
b. Intravenous antibiotics
CLINICAL ASSESSMENT OF THE FACE
Inspection and documentation of all lacerations and facial nerve function
CRANIOFRONTAL FRACTURES
 Direct high-velocity injury
 Burst lacerations
 Periorbital ecchmoses
 Contour deformities
 Intracranial injury and CSF rhinorrhea
 Impingement on the orbit (intraorbital structures, globe displacement, volumetric
changes, ptosis, diplopia, limitation of supraduction)
ORBITAL FRACTURES
 Globe trauma
 Entrapped inferior rectus
 Restriction of ocular motility and diplopia (muscle contusion, fat or muscle
entrapement, traumatic neuropathy)
NASOETHMOID FRACTURES
 Anatomically interorbital space
 Fractures potentially involve cranial, orbital, and nasal cavities
 Exaggerated depth of the nasofrontal angle and decreased projection of the nasal
dorsum, nasal airway obstruction epistaxis
 Nasolacrimal duct obstruction
 Rounding of the medial canthus
 Increased intracanthal distance
 Diminished palpebral fissure width
 Delicate framework and comminute readily
ZYGOMATIC FRACTURES
 Zygoma defines facial width, cheek prominence and the transverse and vertical
dimensions of the orbit and contributes to the lateral and inferior orbital walls
 Subconjunctival haemorrhage
 Sensory changes to cheek, upper lip and gingival
 Malar is depressed
 Trismus (restriction of mandibular excursion)
 Look for signs of significant orbital floor fractures
 Unilateral epistaxis
 Step deformity and tenderness inferior orbital rim, ZF suture, zygomatic arch,
lateral midface buttress
MAXILLARY FRACTURES
 Functionally maxilla contributes to vertical height and projection of the midface in
relation to the cranial base
 Transverse and vertically thickened buttresses
 Clinical:
Sub conj. Haematoma
Flattening and elongation of the face
Malocclusion
Epistaxis and nasal airway obstruction
Orbital extension with Lefort I and II
Palatal fractures and lacerations
Degree of instability established
DON’T FORGET ASSOCIATED MANDIBULAR FRACTURES
RADIOLOGICAL ASSESSMENT
o
o
o
o
o
Plain films
Axial and coronal CT (either true coronal or coronal reconstructions)
Assess fracture pattern and displacement, intracranial and intraorbital status
3D reconstructions
OPG
PRINCIPLES OF FACIAL FRACTURE AND SOFT TISSUE REPAIR
TREATMENT GOALS AND PRICIPLES
 Accurate and comprehensive diagnosis
 Direct fracture exposure
 Precise anatomic reduction
 Rigid internal fixation of all fracture fragments, beginning with stabilization of the
mandible and including reconstruction of the horizontal and vertical facial
buttresses
 Primary bone grafting for volumetric and three-dimensional reconstruction of all
skeletal defects
 Periosteal suspension of the soft tissues after fracture reduction
TIMING
 Single stage within 24-48 hours
 Practically wait for decreased swelling within 1 week (up to 2 weeks)
 Delay if patient unstable
EXPOSURE
 Obtain wide exposure
 The entire craniofacial skeleton can be visualized through 4 incisions
1. Coronal
2. Transconjunctival or subciliary lower lid incision
3. Upper gingivobuccal incision
4. Approaches for the mandible
PRINCIPLES OF FRACTURE REPAIR
 Early one stage repair
 Wide Exposure
 Premorbid occlusion is reestablished – IMF
 Work from stable to unstable
 Start with upper 1/3rd or mandible (preference)
 Identify stable uninjured portions for reference
 Vertical and horizontal buttresses reconstructed
 Disimpaction
 Precise anatomic reduction
 Rigid fixation
 Immediate bone grafting
 Resuspension of soft tissues
DEFINITIVE SOFT TISSUE REPAIR
1. Debridement
2. Repair of lacerations
a. Including parotid duct, nasolacrimal duct, facial and sensory nerves
b. Important to return displaced anatomical landmarks to there premorbid
position
3. Tissue loss assessment and replacement
4. Controlled soft-tissue redraping
a. Obvious in periorbital region, height and width of the palpebral fissure