midface fractures evaluation and management e.razmpa m.d otolaryngologist head & neack surgeon...
TRANSCRIPT
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Midface Fractures Evaluation and Management
E.RAZMPA M.D
OTOLARYNGOLOGIST
HEAD & NEACK SURGEON
ASSOCIATE PROFESSOR
TEHRAN UNIVERSITY OF MEDICAL SCIENCES
www.razmpa .comwww.razmpa .com
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Etiology
• Motor Vehicle Accidents
• Assault
• Sport
• Falls
• Work
• Pathological
Midface FracturesMidface Fractures
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Midface FracturesMidface Fractures
• Osteology of the midface– 2 maxillae– 2 zygomata– 2 zygomatic proceses of temporal bone– 2 palatine bones– 2 nasal bones– 2 inferior conchae– 2 pterygoid plates of sphenoid bone
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Midface FracturesMidface Fractures
• Three buttresses allow face to absorb force– Nasomaxillary
(medial) buttress– Zymaticomaxillary
(lateral) buttress– Pyterigomaxillary
(posterior) buttress
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Classification
• Anatomical– Lefort
• I• II• III• Unilateral• Sagittal
– Wassmund
• Severity– Cooter and David– MFISS
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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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– 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
Lefort Classification
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Midface FracturesMidface Fractures
• LeFort I : Transverse Maxillary• Lefort II : Pyramidal• Lefort III : Craniofacial Disjunction• Zygomatic Complex• Orbital Floor • Nasal Fractures• Naso-orbital/Ethmoid
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LeFort - AP view
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Le Fort I
• Low level
• Often mobile
• Mild swelling
• Disturbed occlusion
• Deviated midline
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Lefort I FractureTransverse Maxillary
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Le Fort II
• Subzygomatic pyramidal
• Gross swelling
• Immobile
• Anterior open bite
• Altered sensation
• Long faced appearance
• CSF rhinorrhoea
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Lefort II FracturePyramidal
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Le Fort III• Suprazygomatic craniofacial disjunction
• Gross swelling
• Immobile
• Altered occlusion with AOB
• Long faced appearance
• Flattened cheek prominence
• CSF rhinorrhoea
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Lefort III FractureCraniofacial Disjunction
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Blow Out Fractures• Compression of orbital contents deforms the
orbital– Floor– Walls– Roof
• May result in– Diplopia– Restricted eye movements– Enophthalmos– Superior orbital fissure syndrome
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Nasoethmoidal Injuries• Central midface
• Traumatic telecanthus or hyperteleorism
• Nasal deformity
• Orbital wall involvement– Enophthalmos– Diplopia
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Diagnosis of Maxillofacial Injuries
• Inspection
• Palpation
• Diagnostic Imaging– Plain films– CT– Stereolithography (where available)
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Midface FracturesMidface Fractures
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Inspection
Sublingual ecchymosisSublingual ecchymosis Step defects, ridgediscontinuity, malocclusionStep defects, ridgediscontinuity, malocclusion
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Diagnosis of Maxillofacial Injuries
• PALPATION– “Step” Defect– Crepitus
• Bony segments• Subcutaneous
emphysema• Mobility
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Facial ExaminationPalpation of Midface/bridge of nose
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Facial ExaminationOrbits Evaluation
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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 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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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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Lefort I Fractures
Signs and Symptoms
• Damaged teeth and soft tissues
• Swelling and bruising
• Deformity of alveolus
• Malocclusion
• Independent movement of fragments
• Altered sensation
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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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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 of Maxillofacial Injuries
• DIAGNOSTIC IMAGING– Panorex– Plain films– CT– Stereolithography
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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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Lateral C-Spine Film
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C-spine CTs
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3D CT
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Stereolithography
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Radiographic Evaluation
Stereolithography allows actual model of defect. A nice reconstruction tool to use if available
Stereolithography allows actual model of defect. A nice reconstruction tool to use if available
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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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Principles
• First Aid– Airway– Breathing– Circulation
• Resuscitation
• Exclusion of other injury
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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
• 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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Airway Management
• Chin lift to open intact airway
• Intubation– Oral: C-spine injury absent on X ray– Nasotracheal intubation: C-spine injury suspected
• 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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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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Facial lacerations
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Soft tissue injury
• Hemostasis
• Debridement
• Approximate wound edges– Sutures– Steristrips
• Dressings
• Antibiotics/Tetanus
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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!
Remember to think in 3Dfor there are alwaysother structures involved!
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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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Facial Fractures• Hemorrhage
– Anterior cranial fossa– Midface– Lacerations– Nasal
• Nasal, zygomatic, orbital, frontal, NOE, maxillary– Reduction (IMF)– Anterior/ posterior packing x 24-48 hrs– Compression dressing– Embolization– Bilateral external carotid/ superficial temporal ligation– Blood factor replacement
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Treatment• Conservative• Closed Reduction
– External fixation
• Open Reduction– Internal fixation
• Wires– Suspension– Osteosynthesis
• Screws• Plates
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Treatment• Open reduction
– Direct visual access to the fracture– Anatomical reduction of bone fragments
• Fixation– Wire osteosynthesis– Screw fixation– Plate fixation
• Miniplates• Reconstruction plates
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Treatment
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 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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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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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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Lefort II & III Reconstruction
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Lefort II & III Reconstruction
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• Open Reduction
• Fixation– Miniplates
• Orbital defect reconstruction– Silicone– Titanium– Autologous Bone
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Orbital Floor Treatment
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Orbital Floor Treatment
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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
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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 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 Fractures
• Depression or angulation
• Periorbital ecchymosis
• Epistaxis
• Tenderness
• Crepitus
• Septal deviation
• Septal hematoma
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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 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 Hemorrhage
• Nasal packing• Merocel sponge• Nasopharyngeal balloon
– Epistat– Foley catheter
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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
architecture
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Nasal-Orbital-Ethmoid FracturesCT Scans
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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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Surgical exposureBicoronal
Periocular/transconjunctival
Intraoral
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Nasal-Orbital-Ethmoid Fractures
Surgical Reduction
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Nasal-Orbital-Ethmoid FracturesSurgical Reduction
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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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Postoperative care
• Airway– Avoidance of IMF in post op period– Nasopharyngeal airway– Tracheostomy
• Analgesia
• Antibiotics
• Fluids and diet
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