head and neck trauma by dr. kenneth dickie
DESCRIPTION
Dr. Kenneth Dickie from Royal Centre of Plastic Surgery in Barrie, Ontario explained the care for Head & Neck Trauma. f you have any questions, please contact Dr. Kenneth Dickie at http://royalcentreofplasticsurgery.com/TRANSCRIPT
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Head & Neck Trauma
Dr. Kenneth DickieRoyal Centre of Plastic Surgery
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Head and Neck Trauma
Evaluation and Management
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Maxillofacial Injuries
• Treatment divided into following phases– Emergency or initial care– Early care– Definitive care– Secondary care or revision
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Emergency Care
• Preserve the airway• Control of hemorrhage• Prevent or control shock• C-Spine stabilization• Control of life-threatening injuries– head injuries, chest injuries, compound limb
fractures, intra-abdominal bleeding
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Emergency Care
• Evaluate the airway– Existence & identification of obstruction– Manually clear of fractured teeth, blood clots,
dentures– Endotracheal intubation & packing of oronasal
airway
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Emergency Care
• Airway Management– Maintain an intact airway– Protect airway in jeopardy– Provide an airway
• C-Spine injury may be present• Altered level of consciousness is the most
common cause of upper airway obstruction
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Airway Management• Chin lift to open intact
airway• Intubation– Oral: C-spine injury absent on X
ray– Nasotracheal intubation: C-spine injury
suspected or certain
• Surgical Airway– Cricothyroidotomy– Tracheosotomy
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Emergency Care
• Extensive vascularity of head & neck may lead to massive blood loss– Monitor vital signs closely– Intravenous infusion
• Penetrating injuries need to be explored– Arteriogram– Esophagram
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Treatment of Blood Loss & Shock
• Hemorrhage most common cause of shock after injury
• Multiple injury patients have hypovolemia• Goal is to restore organ
perfusion
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Treatment of Blood Loss & Shock
• External bleeding controlled by direct pressure over bleeding site
• Gain prompt access to vascular system with IV catheters
• Fluid replacement– Ringer’s Lactate– Normal saline– Transfusion
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Stabilization of associated injuries
• C-spine injury is primary concern with all maxillofacial trauma victims– Any patient with injury above clavicle or head
injury resulting in unconscious state– Any injury produced by high speed– Signs/symptoms of C-Spine injury• Neurologic deficit• Neck pain
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Stabilization of associated injuries
• C-spine injury suspected– Avoid any movement of spinal
column– Establish & maintain proper
immobilization until vertebral fractures or spinal cord injuries ruled out• Lateral C-spine radiographs• CT of C-spine• Neurologic exam
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Head/Neck/C-Spine Stabilization
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Lateral C-Spine Film
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C-spine CTs
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Early Care
– Emergency care has stabilized patient– Initial stabilization of fractures– Debridement & dressing of soft tissues– Elective tracheostomy– Physical exam & history– Laboratory tests– Complete head & neck examination• Diagnosis of maxillofacial injuries
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Diagnosis of Maxillofacial Injuries
• Inspection• Palpation• Diagnostic Imaging– Plain films– CT– Stereolithography (where available)
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Diagnosis of Maxillofacial Injuries
• INSPECTION– Hemorrhage– Otorrhea– Rhinorrhea– Contour deformity– Ecchymosis– Edema– Continuity defects– Malocclusion
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Inspection
Sublingual ecchymosis Step defects, ridgediscontinuity, malocclusion
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Diagnosis of Maxillofacial Injuries
• PALPATION– “Step” Defect– Crepitus• Bony segments• Subcutaneous
emphysema• Mobility
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Diagnosis of Maxillofacial Injuries
• DIAGNOSTIC IMAGING– Panorex– Plain films– CT– Stereolithography
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CT Scans
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3D CT
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Stereolithography
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Definitive Care
• Soft Tissue Injuries– Contusions– Abrasions– Lacerations
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Soft tissue injury
– Facial lacerations not complicated by associated injury can be managed in an ER setting
– Large extensive facial and scalp lacerations are preferably closed in an operating room environment
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Soft tissue injury
• Hemostasis• Debridement• Approximate wound edges– Sutures– Steristrips
• Dressings• Antibiotics/Tetanus
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Facial lacerations
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Associated Soft Tissue Injury
• Lacrimal System• Parotid Duct• Facial Nerve– Surgical repair if posterior to vertical line
drawn from outer canthus of eye
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Associated Soft Tissue Injury
Remember to think in 3Dfor there are alwaysother structures involved!
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Mandibular Fractures
• Mandible is second most common fractured facial bone
• 50% of mandibular fractures are multiple– Examine patient and
radiographs closely and suspect additional fractures
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Mandibular Fractures
• Clinical Signs and Symptoms– Tenderness & pain– Malocclusion– Ecchymosis in floor of
mouth– Mucosal lacerations– Step defects inferior border– CN V3 Disturbances
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Mandibular Fractures
• Treatment depends on fracture site and amount of segment displacement
• Closed reduction– Application of arch bars– Placement into intermaxillary fixation (IMF)
• Open Reduction– Internal wire fixation– Bone plates
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Closed Reduction with IMF
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Open Reduction
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Open Reduction
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Midface Fractures
• LeFort I Transverse Maxillary• Lefort II Pyramidal• Lefort III Craniofacial Dysjunction• Zygomatic Complex• Orbital Floor • Nasal Fractures• Naso-orbital/Ethmoid
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Midface Fractures
• Three buttresses allow face to absorb force– Nasomaxillary (medial)
buttress– Zymaticomaxillary
(lateral) buttress– Pyterigomaxillary
(posterior) buttress
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Lefort Classification
• Weakest areas of midfacial complex when assaulted from a frontal direction at different levels (Rene’ Lefort, 1901)– Lefort I: above the level of teeth– Lefort II: at level of nasal bones– Lefort III: at orbital level
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Lefort Classification
– Provides uniform method to describe the level of major fracture lines
– Allows references regarding the probable points of stability for surgical treatment
– Does not incorporate vertical or segmental fractures, comminution or bone loss
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Lefort I FractureTransverse Maxillary
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Lefort II FracturePyramidal
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Lefort III FractureCraniofacial Dysjunction
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Facial Examination
• Evaluate for laceration• Obvious depression in skull• Asymmetry• Discharge from nose or ear– Assume CSF leak
• Palpation to note bone discontinuity– Bimanually in systematic manner
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Facial Examination• Evaluate mandibular opening• Palpation of buccal vestibule
Crepitus of lateral antral wall• Occlusion evaluated
Absence and quality of dentition noted
• Ecchymosis common finding• Pharynx evaluated for
laceration & bleeding
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Facial Examination
• Orbits evaluated– Periorbital edema and
ecchymosis– Gross visual acuity
determined– Diplopia– Pupillary size & shape– Subconjunctival hemorrhage– Funduscopic evaluation
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Facial Examination
• Orbits evaluated– Lid lacerations– Attachment of medial
canthal tendon• Rounding of lacrimal lake• Increased intercanthal
distance• Epiphora
– Prompt Ophthamology consult
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Facial ExaminationOrbits Evaluated
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Facial ExaminationPalpation of Midface/bridge of nose
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Radiographic Evaluation
• Plain Films– Lateral Skull– Waters View– Posteroanterior view of skull– Submental vertex
• CT Scan– 1.5 mm cuts– axial and coronal views
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Radiographic Evaluation
Lateral skull Water’s View
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Radiographic Evaluation
CT Scan 3D CT
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Radiographic Evaluation
Stereolithographyallows actual modelof defect. A nice reconstruction tool to use if available
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Treatment of Midface Fractures
• Once patient’s condition stabilized, no need to rush to surgery– Address rapidly developing
edema– Formulate treatment plan– Observe sequelae in the case of
orbital injuries
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Diagnosis of Lefort I Fractures
• Direction of force• Maxilla displaced posteriorly
and inferiorly– Open bite deformity
• Hypoesthesia of infraorbital nerve
• Malocclusion• Mobility of maxilla– Noted by grasping maxillary
incisors
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Treatment of Lefort I Fractures
– Direct exposure of all involved fractures
– Reduction and anatomic realignment of the maxillary buttresses to reestablish• Anterior projection• Transverse width• Occlusion
– Restoration of occlusion using IMF
– Internal fixation using miniplate fixation
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Treatment of Lefort I Fractures
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Diagnosis of Lefort II and III
• Clinical evaluation provides only a rough impression since swelling hides the underlying bony structures
• Plain film radiographs and axial and coronal CT images are the basis for precise diagnosis & treatment plan
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Diagnosis Lefort II and III
• Bilateral periorbital edema & ecchymosis
• Step deformity palpated infraorbital & nasofrontal area
• CSF rhinorrhea• Epistaxis
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Treatment of Lefort II and III
• Fractures should be treated as early as the general condition of the patient allows
• Team approach to treatment– Neurosurgery– Ophthamology– ENT– Plastic surgery– Oral/Maxillofacial surgery
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Treatment of Lefort II and III
• Intubation must not interfere with ability to use IMF
• Exposure & visualization of all fractures– Approaches to inferior rim• Infraorbital• Subciliary• Transconjunctival• Mid lower lid
– Coronal approach– Gingivobuccal incision
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Fractures
Teeth and occlusion are the key to
reconstruction and provide the
foundation upon which other facial
structures are built
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Treatment of Lefort II and III
– Severely comminuted fractures preliminary approximation may be performed with wire
– Establishment of the correct occlusion– Correct reconstruction of the outer facial
frame for proper facial dimensions– Correct position for nasoethmoidal complex
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Treatment of Lefort II and III
– Reestablishment of the correct intercanthal distance
– Infraorbital rim fixated– Orbit is reconstructed– Occlusion unit with IMF is fixated
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Lefort II & III Reconstruction
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Lefort II & III Reconstruction
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Nasal-Orbital-Ethmoid (NOE) Fractures
– Usually not isolated event– Frequently associated with
multiple midface fractures– Secondary to traumatic insult to
radix area of nose– Low resistance to directional
force• 35-80 gm necessary to
produce fracture
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Nasal-Orbital-Ethmoid Fractures
• Diagnosis– Ophthalmalogic evaluation• Document visual acuity• Pupillary response to light
– Neurologic evaluation• Frontal lobe contusion• Glasgow coma scale
– Increase in ICP and need for monitoring
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Nasal-Orbital-Ethmoid Fractures
• Nasal fracture• Comminuted with posterior
displacement• Widened nasal bridge• Splaying of nasal complex
– Epistaxis– Severe periorbital edema &
ecchymosis– Subconjunctival hemorrhage
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Nasal-Orbital-Ethmoid Fractures
• Clinical signs & symptoms– Traumatic telecanthus• Difficult to measure due to
edema– Average 33-34 mm
• Can measure interpupillary distance and divide in half for approximate intercanthal distance– Average 60-65 mm
– Damage to lacrimal apparatus-epiphora
– CSF leak
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Nasal-Orbital-Ethmoid Fractures
• Radiographic examination– CT - definitive imaging modality• Axial images supplemented
with coronal• Plain films to fail
demonstrate the degree and location of fractures secondary to over-lapping of bony archi- tecture
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Nasal-Orbital-Ethmoid FracturesCT Scans
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Nasal Fractures
• Depression or angulation
• Periorbital ecchymosis• Epistaxis• Tenderness• Crepitus• Septal deviation• Septal hematoma
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Nasal Hemorrhage
• Nasal packing• Merocel sponge• Nasopharyngeal
balloon– Epistat– Foley catheter
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Nasal-Orbital-Ethmoid Fractures
• Nasal fractures– Rule out septal hematoma– Remove clots with suction, incise
and drain if present to prevent septal necrosis
– Closed reduction for simple fractures
– Open reduction for severely displaced fractures
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Nasal-Orbital-Ethmoid FracturesNasal Fractures
• Treatment– Restoration of form and
function– Proper reduction of nasal
fractures– Correction of medial
canthal ligament disruption– Correction of lacrimal
system injuries
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Nasal-Orbital-Ethmoid Fractures
• Surgical considerations– Definitive surgery as soon as
possible after:• Appropriate consultations• Definitive radiographic
imaging• Significant edema allowed
to resolve
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Nasal-Orbital-Ethmoid Fractures
• Surgical considerations– The final phase involves reduction of the NOE
and nasal bone fractures– Access to NOE through existing lacerations,
bicoronal flap, or local incisions
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Nasal-Orbital-Ethmoid Fractures
• Lacrimal system injury– When the medial canthal ligament has been
injured or displaced, damage to the lacrimal system should be assumed
– Nasolacrimal duct is often damaged within its bony course
– Epiphora: Need to evaluate patency of the nasolacrimal system
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Nasal-Orbital-Ethmoid FracturesSurgical Reduction
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Nasal-Orbital-Ethmoid FracturesSurgical Reduction
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Gunshot wound management
• Advanced trauma life support– Primary survey• ABC’s• C-Spine stabilization• Neurological assessment
– Secondary survey• Determine extent of injury
– Definitive treatment
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Animal Bites– Hemostasis– Debridement– Approximate wound
edges– Dressings– Antibiotics/Tetanus• Augmentin
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Radiologic Assessment
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Radiologic Assessment
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Radiologic Assessment
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Radiologic Assessment
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If you have any questions, feel free to contact Dr. Kenneth Dickie at royalcentreofplasticsurgery.com
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