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    MAXILLOFACIAL TRAUMA

    DR.SHANTI

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    Etiology and Incidence

    Multisystem injury 20-50%

    Nasal and mandibular fractures most common

    Midface and zygomatic injuries 2nd most

    common

    25% of women with facial trauma result ofdomestic violence

    Incidence of concomitant cervical spine injurieswith facial fractures

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    Causes of Mortality

    Acute

    Airway compromise

    Exsanguination(severe bleeding) Associated intracranial or cervical-spine injury

    Delayed

    Meningitis

    Oropharyngeal infections

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    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

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    Anatomy

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    Anatomy

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    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

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    Physical Examination

    Inspect the nose for asymmetry,telecanthus(abnormally increased distancebetween the medial canthi of the eyelids),

    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 andtemporal bone.

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    Physical Examination

    Check facial stability.

    Inspect the teeth for malocclusions, bleeding

    Intraoral examination: Manipulation of each tooth.

    Check for lacerations.

    Stress the mandible.

    Tongue blade test.

    Palpate the mandible for tenderness, swellingand step-off.

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    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..

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    Physical Examination

    Examine the cornea for abrasions and

    lacerations.

    Examine the anterior chamber for blood orhyphema(bleeding in the anterior chamber(the space between the cornea and the iris) of

    the eye.)

    Perform fundoscopic exam and examine the

    posterior chamber and the retina.

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    Frontal Sinus/ Bone FracturesPathophysiology

    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 Fractures

    Clinical Findings

    Disruption orcrepitance orbital rim

    Subcutaneousemphysema

    Associated with alaceration

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    Frontal Sinus/ Bone Fractures

    Diagnosis

    Radiographs:

    Facial views should

    include Waters,Caldwell and lateralprojections.

    Caldwell view bestevaluates the anteriorwall fractures.

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    Frontal Sinus/ Bone Fractures

    Diagnosis

    CTHead with bonewindows:

    Frontal sinus fractures. Orbital rim and

    nasoethmoidalfractures.

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    Frontal Sinus/ Bone FracturesTreatment

    Patients with depressed skull fractures or with

    posterior wall involvement IV antibiotics.

    Tetanus.

    Patients with isolated anterior wall fractures,

    nondisplaced fractures can be treated outpatientafter consultation with neurosurgery.

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    Frontal Sinus/ Bone FracturesComplications

    Associated with intracranial injuries:

    Orbital roof fractures. Dural tears.

    Mucopyocoele.

    Epidural empyema.

    CSF leaks.

    Meningitis.

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    Naso-Ethmoidal-Orbital

    Fracture Fractures that extend

    into the nose through theethmoid bones.

    Associated with lacrimaldisruption and duraltears.

    Suspect if there is trauma

    to the nose or medialorbit.

    Patients complain of painon eye movement.

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    Naso-Ethmoidal-Orbital

    Fracture Clinical findings:

    Flattened nasal bridge or a saddle-shapeddeformity of the nose.

    Widening of the nasal bridge (telecanthus)

    CSF rhinorrhea or epistaxis.

    Tenderness, crepitus, and mobility of the nasalcomplex.

    Intranasal palpation reveals movement of themedial canthus.

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    Naso-Ethmoidal-Orbital

    Fracture Imaging studies:

    Plain radiographs are insensitive.

    CT of the face with coronal cuts through themedial orbits.

    Treatment:

    Maxillofacial consultation.

    Antibiotic

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    Nasal 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 Fractures

    Clinical findings:

    Nasal deformity

    Edema and tenderness Epistaxis

    Crepitus and mobility

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    Nasal Fractures

    Diagnosis:

    History and physical

    exam. Lateral or Waters view

    to confirm yourdiagnosis.

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    Nasal Fractures

    Treatment:

    Control epistaxis.

    Drain septalhematomas(it maybecome infected andpainful and develop aseptal abscess

    Nasal bone reduction

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    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

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    Orbital Blowout Fractures

    Clinical Findings Periorbital tenderness,

    swelling,

    ecchymosis(bruise) Enopthalmus or sunken

    eyes.

    Impaired ocular

    motility. Infraorbital anesthesia.

    Step off deformity

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    Orbital Blowout Fractures

    Imaging studies Radiographs:

    Hanging tear drop sign

    Open bomb bay door Air fluid levels

    Orbital emphysema

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    Orbital Blowout Fractures

    Imaging studies CT of orbits

    Details the orbital

    fracture Excludes retrobulbar

    hemorrhage.

    CTHead

    R/o intracranial injuries

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    Orbital Blowout Fractures

    Treatment Blow out fractures require

    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 furthercare.

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    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)

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    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.

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    Zygoma Arch Fractures

    Clinical Findings Palpable bony defect

    over the arch

    Depressed cheekwith tenderness

    Pain in cheek and jawmovement

    Limited mandibularmovement

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    Zygoma Arch Fractures

    Imaging Studies & Treatment Radiographic

    imaging:

    Submental view(bucket handle view)

    Treatment:

    Ice and analgesia

    Possible openelevation

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    Zygoma Tripod Fractures Tripod fractures

    consist of fractures

    through: Zygomatic arch

    Zygomaticofrontalsuture

    Inferior orbital rim andfloor

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    Tripod Fracture

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    Zygoma Tripod Fractures

    Clinical Features Clinical features:

    Periorbital edema and

    ecchymosis(bruise) Hypesthesia (sensory

    loss )of the infraorbitalnerve

    Palpation may revealstep off

    Concomitant globeinjuries are common

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    Zygoma Tripod Fractures

    Imaging Studies Radiographic

    imaging:

    Waters, Submentaland Caldwell views

    Coronal CT of thefacial bones:

    3-D reconstruction

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    Zygoma Tripod Fractures

    Treatment Nondisplaced fractures without eye involvement

    Ice and analgesics

    operative consideration within 5-7 days

    Decongestants

    Broad spectrum antibiotics

    Tetanus

    Displaced tripod fractures usually require openreduction and internal fixation.

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    Maxillary 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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    LeFort Fractures

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    Maxillary Fractures

    LeFort I Definition:

    Horizontal fracture of

    the maxilla at the levelof the nasal fossa.

    Allows motion of themaxilla while the nasalbridge remains stable.

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    Maxillary Fractures

    LeFort I Clinical findings:

    Facial edema

    Malocclusion of theteeth

    Motion of the maxillawhile the nasal bridge

    remains stable

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    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

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    Maxillary Fractures

    LeFort II Definition:

    Pyramidal fracture

    Maxilla Nasal bones

    Medial aspect of theorbits

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    Maxillary Fractures

    LeFort II Clinical findings:

    Marked facial edema

    Nasal flattening Traumatic telecanthus

    Epistaxis or CSFrhinorrhea

    Movement of theupper jaw and thenose.

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    Maxillary Fractures

    LeFort II Radiographic

    imaging:

    Fracture involves: Nasal bones

    Medial orbit

    Maxillary sinus

    Frontal process of the

    maxilla

    CT of the face andhead

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    Maxillary Fractures

    LeFort III Definition:

    Fractures through:

    Maxilla Zygoma

    Nasal bones

    Ethmoid bones

    Base of the skull

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    Maxillary Fractures

    LeFort III Clinical findings:

    Dish faced deformity

    Epistaxis and CSFrhinorrhea

    Motion of the maxilla,nasal bones andzygoma

    Severe airwayobstruction

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    Maxillary Fractures

    LeFort III Radiographic

    imaging:

    Fractures through: Zygomaticfrontal suture

    Zygoma

    Medial orbital wall

    Nasal bone

    CT Face and the Head

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    Maxillary Fractures

    Treatment Secure and airway

    Control Bleeding

    Head elevation 40-60 degrees antibiotics

    Reduction,fixation and recontruction done

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    Mandible Fractures

    Pathophysiology Mandibular fractures are

    the third most commonfacial fracture.

    Assaults and falls on thechin account for most ofthe injuries.

    Multiple fractures are

    seen in greater then 50%.

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    Mandible Fractures

    Clinical findings Mandibular pain.

    Malocclusion of the teeth

    Separation of teeth withintraoral bleeding

    Inability to fully openmouth.

    Preauricular pain with

    biting. Positive tongue blade

    test.

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    Mandible Fractures

    Radiographs:

    Panoramic view

    Plain view: PA, Lateral and a Townes view

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    Mandibular Fractures

    Treatment Nondisplaced fractures:

    Analgesics

    Soft diet

    oral surgery

    Displaced fractures, open fractures and fractureswith associated dental trauma Urgent oral surgery consultation

    All fractures should be treated with antibioticsand tetanus prophylaxis.

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    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

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    Mandibular Dislocation

    The mandible can bedislocated:

    Anterior 70% Posterior

    Lateral

    Superior

    Dislocations aremostly bilateral.

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    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

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    Mandibular 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 Dislocation

    Treatment:

    Muscle relaxant

    Analgesic Closed reduction

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    Emergency Management

    Intubation 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 Management

    Intubation Considerations Consider fiberoptic intubation if available.

    Alternatives include percutaneous

    transtracheal ventilation and retrogradeintubation.

    Be prepared for cricothyroidotomy.

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    Emergency Management

    Hemorrhage 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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    Thank you