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Maxillofacial Trauma Maxillofacial Trauma • • • • • Common as a result of blunt injury Mandibular:Zygoma:Maxillary in ratio of 6:2:1 50% due to assaults 50% of which alcohol related 25% of women with facial trauma are victims of domestic violence Need ATLS approach A. Main cause of death = airway obstruction • May require surgical airway • 10-15% have C-spine injury (if unconscious) B. At risk of aspiration – missing teeth C. Significant haemorrhage can be difficult to control D. Facial injury = head injury Pathophysiology • 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 General Examination • Look for swelling/bruising/deformity etc. • Palpate all bony margins for tenderness and steps • Intra-oral examination • Facial stability • Facial sensation • Eye examination Mandibular Injury • Assaults and falls on the chin account for most of the injuries • Often injured at site distant from point of impact • Multiple fractures are seen in greater then 50% • Condyler fractures commonly missed • Usually open #’s Clincial Features • Occlusion of bite is the key point in history • Parasthesia of mental nerve • Intra-oral examination important (Sublingual haematoma). Crepitus + mobility • TMJ and ear examination Mandible Imaging • OPT (oral-pan-tomogram) OPG (ortho-pan-tomogram) • PA mandible ± Lateral oblique Mandibular Fracture Management • Undisplaced fractures: – Analgesics – Soft diet – Max-fax referral – usually outpatient • Displaced fractures and those associated with dental trauma – Max-fax referral for inpatient care • All fractures should be treated with antibiotics and tetanus prophylaxis. TMJ Dislocation • Causes of mandibular dislocation are: – Blunt trauma – Excessive mouth opening – clinical diagnosis • The mandible can be dislocated: – – – – Anterior 70% Posterior Lateral Superior • Mostly bilateral Treatment: • Analgesic • Manual reduction • ±Sedation – Soft Diet – Avoid Mouth opening Zygoma Fractures • Direct blunt trauma most common cause • Two types of fractures can occur – Arch fracture (most common) – Tripod fracture (most serious) • Zygomatic arch • Zygomaticofrontal suture • Inferior orbital rim and floor Clinical Features • • • • • Palpable bony defect over the arch Depressed cheek with tenderness Pain in cheek and jaw movement Limited mandibular movement Infra-orbital nerve parasthsia in 80-90% Midface fractures High energy injury • Le Fort I – Low level maxilla fracture – May have elongated face – Movement of maxilla, but nose stable • Le Fort II – Pyramidal or nasomaxillary fracture – Dished in face followed by evere facial swelling – Movement of maxilla and nose • Le Fort III – Craniofacial dysjunction – Mid face fractured off skull base - mobile – Risk of severe pharyngeal bleeding CSF leaks are common with Le Fort II & III fractures These fractures may be asymmetrical Orbital floor/Peri-orbital Injuries • Consider associated eye injury with any facial injury – thus all require eye exam – – – – – Ophthalmoplegia & Diplopia Hypoglobus Enophthalmus Proptosis Visual loss – Lid and lacrimal duct damage Orbital Blowout Fractures • Occur when the the globe sustains a direct blunt force • Imaging: – Hanging tear drop sign – Open bomb bay door – Air fluid levels – Orbital emphysema Imaging • Occipto-mental (OM) 15/30 views • Submento-vertical view for arch fractures – Maxillary sinus opacification – Follow McGrigors lines OM Hotspots Reviewing facial Xrays Facial Fracture Management • • • • • • ABCDE approach Protect airway if needed Control Bleeding If able, more comfortable sitting up Max-fax review Consider antibiotics Management • Surgery is indicated if – – Impairment of function: ↓mouth opening – Displaced fractures – ?Cosmetic concern – Often best performed when swelling settled • Avoid nose blowing (surgical emphysema) and pressurised environments • Soft Diet Others • • • • Dento-alveolar injury Frontal sinus fracture Naso-ethmoid fracture Nasal fracture Questions? ? Summary • • • • • • • Commonly related to blunt trauma Mandibular:Zygoma:Maxillary in ratio of 6:2:1 Often needs ATLS style approach Thorough examination Methodical approach to xray review Consider antibiotics and tetanus Involvement of Max-fax team