MIDFACE TRAUMA

MIDFACE TRAUMA Vertical Buttresses

well equipped to withstand forces directed superiorly or inferiorly poorly withstands lateral and frontal forces midface absorbs, conducts and effectively dissipates forces horizontal and vertical buttresses resist/transmit forces to base of skull

zygomatico-

maxillary
pterygomaxillary nasomaxillary

MIDFACE TRAUMA Horizontal Buttresses

MIDFACE TRAUMA

Pyriform Aperture Maxillary Alveolus and Palate Orbital Rims Base of skull

Le Fort I, II & III NOE ZMC isolated maxillary, zygomatic, nasal

EMERGENCY TREATMENT
Airway/Breathing

EMERGENCY TREATMENT
Tracheotomy vs ET tube

airway evaluation supraglottic obstruction due to secretions &/or debris intraoral wounds managed locally ET tube for severe bleeding C-spine fx must be ruled out or stabilized prior to ET tube placement

upper airway obstruction w/ c-spine fx perform trach or cricothyroidotomy avoid c-spine manipulation and movement with ET tube laryngeal fx is indication for trach reconstructive procedure hampered by ET tube

EMERGENCY TREATMENT
Circulation

blood volume: vitals, central subclavian catheter NS or LR through 2 large bore IV lines vascularity of region may result in severe hypovolemia typed/crossmatched blood ateriogram/esophagram

MIDFACE TRAUMA
Sensory Innervation

Classification of Le Fort Fractures

1st & 2nd divisions of trigeminal nerve V2 emerges from infraorbital foramen supplies lateral nasal, inferior palpebral, & superior labial regions

Le Fort I- force delivered above level of teeth Le Fort II- force delivered at level of nasal bones Le Fort III- force delivered at orbital level resulting in craniofacial dysjunction

Classification of Le Fort Fractures

Classification of Le Fort Fractures

Le Fort I Fracture

lateral border of pyriform sinus across lateral antral wall behind maxillary tuberosity across pterygoid jct concomitant nasal septum fx may be present unilateral fx may occur coursing through palatal suture line

Le Fort I Fractures
Muscular Attachments

palatal ecchymosis from unilateral fracture

Le Fort I Fractures

posterior, Findings Physical Examinferior displacement creating a classic open bite

segment can be impacted, immoveable, free floating displacement of fractured fragment CN V injury (infraorbital branch) movement of maxilla in AP direction with no movement of midface

medial pterygoid lateral pterygoid post/inf pull seen in fx of maxilla

Le Fort I Fractures
Fracture Management

Le Fort I Fractures
Fracture Management

minimally displaced fx early MMF 4-6 weeks of immobilization open reduction with plating

significant displacement or impaction disimpaction forceps maxilla pulled forward and down rigid fixation with miniplates skeletal suspension with circumzygomatic wiring external fixation

Le Fort II Fractures

pyramidal fracture fracture line along nasofrontal suture through lacrimal bones across inferior orbital rim in area of ZM suture along lateral antral wall at jct of pterygoid plates

Le Fort II Fractures
Physical Exam Findings

Le Fort II Fractures
Physical Exam Findings CSF rhinorrhea due to dural tear lateral to cribriform plate disruption of sphenoid, ethmoid, and frontal sinuses leakage generally noted immediately following trauma

bilateral periorbital edema and eccymosis; raccoon sign CN V injury (infraorbital nerve) malocclusion, open bite step deformity of infraorbital rim region or nasofrontal suture region mobility of fractured complex by grasping the mx anterior teeth and moving complex AP orbital blowout fx epistaxis

Le Fort II Fractures
Le Fort II FracturesPhysical Exam Findings

Considerations within ER setting

diagnosis of CSF is difficult if mixed with blood must be distinguished from nasal secretions & lacrimal secretions Glucose level of 45mg/dL will not stiffen handkerchief or guaze forms characteristic concentric rings pt may report salty taste high resolution CT cisternogram w/ intrathecal florescein beta-2-transferrin

semirecumbent position no nose blowing, no straining, sneezing with mouth open abx therapy to counter development of meningitis

Le Fort II Fracture
TREATMENT

IMF x 4-6 weeks disimpaction forceps orbital floor exploration and release of entraped muscle rigid fixation across nasofrontal sutures, zygomaticomaxillary sutures, or inferior orbital rims

Le Fort III Fractures

fx courses through ZT and ZF sutures along lateral orbital wall through inferior orbital fissure medially through nasofrontal suture ending at pterygomaxillary fissure

Le Fort III Fracture

Physical Exam Findings

Le Fort III Fracture

Treatment

mobility of zygomaticomaxillary complex CSF leakage periorbital edema and ecchymosis traumatic telecanthus epiphora epistaxis

establish outer framework immobilization of ZF, ZT and NF sutures if mand or mx involved 1st establish proper occlusion bicoronal, infraorbital, lateral brow &/or nasofrontal incision expose nasoethmoid complex, lateral rims and zygomatic arch

Zygomaticomaxillary Complex (ZMC)Fractures

zygoma is major buttress of the facial skeleton important role in facial contour quadrilateral in shape (4 sided pyramid) articulates with 4 bones fx can result in ocular and mandibular functional impairment origin to masseter muscle & attachment to temporalis fascia, temporal and zygomatic muscles

Zygomaticomaxillary Complex (ZMC)Fractures

2nd most common facial fx after nasal high incidence due to prominent position within facial skeleton male predilection 4:1 2nd and 3rd decades of life altercations & MVA greater incidence of left sided injury b/l fx most commonly result of MVA

ZMC Fractures
Physical Exam Findings

periorbital edema & ecchymosis flattening of malar prominence ecchymosis of maxillary buccal sulcus trismus-impinging coronoid infraorbital nerve deficit epistaxis

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ZMC Fractures

Ocular Exam Findings subconjuctival ecchymosis crepitation from air emphysema displacement of palpebral fissure antimongoloid slant to eye unequal pupillary levels diplopia muscle entrapment & enophthalmus

ZMC Fractures
Treatment Considerations

edema-may need to postpone surgery neurologic state status of contralateral eye prolapse of orbital soft tissue into mx sinus thin plates due to thin periorbital skin

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Naso-Orbital-Ethmoid Fracture
Physical Exam Findings fractured nose

widened nasal bridge epistaxis periorbital edema and ecchymosis disruption of lateral canthal ligament traumatic telecanthus damage to lacrimal apparatus (20% of pts) epiphora

Naso-Orbital-Ethmoid Fracture
Physical Exam Findings

Naso-Orbital-Ethmoid Fracture
Markowitz & Manson Classification System

average intercanthal distance: 33-34mm (males), 32-34mm (females) intercanthal distance > 35mm are suggestive of NOE fx distances >40mm are generally diagnostic intercanthal distance roughly 1/2 the interpupillary distance crepitus/movement of medial orbital rim indicates instability

Class I: canthal ligament attached to large fragement/no comminution Class II: canthal ligament attached to substantial fragment of bone despite some comminution Class III: detachment of canthal ligament, severe comminution, ligament attached to very small fragment of bone

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Naso-Orbital-Ethmoid Fracture
Treatment

Naso-Orbital-Ethmoid Fracture
Nasolacrimal Injury

adequate exposure coronal flap with lower eyelid incisions existing lacerations medial canthal tendon injury may require canthopexy with transnasal wiring ORIF of nasal bones to frontal bone & inferior & medial orbtial rims nasal dorsum bone grafting

loss of protection provided by medial canthal ligament ORIF of fx segments to reestablish lacrimal drainage stent (Crawford tube) to bridge two severed ends & closure of pericannular tissue dacrocystography uncorrected epiphora may require dacrocystorhinostomy

Naso-Orbital-Ethmoid Fracture
Dacrocystorhynostomy

Complications of Midface Trauma

incision midway between corner of eye and bridge of nose lacrimal sac located and connected to nasal mucosa new tear drainage pathway stent placed to prevent scarring

CSF otorrhea & rhinorrhea Damage to Lacrimal System Ocular Neurologic

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Ocular Complications of Midface Trauma

Traumatic Diplopia

most frequent complication usually temporary but may become permanent if not treated must distinguish between neurologic damage and muscle entrapment & edema forced duction test limitation of motion may indicate entrapment absence of resistance may indicate neurologic deficit

Diplopia Enophthalmos Retrobulbar Hematoma Superior Orbital Fissure Syndrome Orbital Apex Syndrome Blindness

Traumatic Diplopia
Causes

Traumatic Diplopia
Treatment

interference with function of EOM displaced globe muscle or fat entrapment bony displacement (orbital floor) displacement of Lockwoods inferior suspensory ligament impingement of CN III, IV, VI
large defects displaced zygoma orbital floor defect with damage to Lockwoods ligament inferior repositioning of globe trap door injury with physical restriction of movement

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Traumatic Diplopia
Treatment

Traumatic Diplopia
Treatment Objectives

edema steroids for 5-7 days determine if diplopia secondary to edema or entrapment CT scan with 3mm cuts result of forced duction test

prevent loss of orbital contents provide support for orbital contents reconstruct floor to mirror opposite side retrieve herniated fat in trap door injury

Traumatic Diplopia
Monocular Diplopia

Enophlalmos
loss/atrophy of orbital fat enlargement of bony orbit cicatricial contraction of retrobulbar tissue unrepaired fracture of orbital wall displacement of orbital tissue increased orbital volume, decrease orbital contents, disruption of ligamentous structures

detached lens hyphema traumatic globe injury

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Enophlalmos
Treatment

Retrobulbar Hematoma

ORIF orbital fx repair orbital floor and restoration of orbital contents freeing of soft tissue from herniated positions repair of zygoma fx
compromise optic nerve function central retinal artery obstruction infraorbital arterial rupture anterior/posterior ethmoid arterial rupture

Retrobulbar Hematoma
Subjective/Objective Findings

Retrobulbar Hematoma
Treatment

severe aching pain progressive loss of vision proptosis increased IOP (normal:12-20mm Hg) subconjunctival hemorrhage gross eyelid swelling fixed, dilated pupil

post-surgical wound opening IV injection of acetazolamide to decrease IOP (up to 500mg) lateral canthotomy

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direct compression or hematoma on contents of superior orbital fissure pupillary dilation due to altered CN III function unopposed sympathetic control paresis of CN III, IV, VI resulting in ophthalmoplegia ptosis from paresis of levator palpebrae superiorus neurosensory disturbance CN V (frontal branch causing loss of sensation over forehead) deficit of supraorbital/supratrochlear nerves loss of corneal reflex (nasociliary branch of CN V) proptosis from engorgement of ophthalmic vein and lymphatics

Superior Orbital Fissure Syndrome

Orbital Apex Syndrome

superior orbital fissure syndrome optic nerve involvement change in visual acuity

Blindness Blindness

Immediate Reduction in IOP

0.03-2.1% retrobulbar hemorrhage occlusion of ciliary arteries ischemia leads to optic neuropathy prompt diagnosis and treatment rapid evacuation of hematoma

20%

mannitol (2g/kg IV, max 12.5g in 3-4min) sodium (Diamox) sodium succinate 500mg IV

Acetazolamide

Methylprednisolone

(Solu-Medrol) 1g IV

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Fonseca R et al, Oral & Maxillofacial Trauma. Vol I &II, 2005 Bagheri S, Jo C, Clinical Review of Oral & Maxillofacial Surgery. 2008 Zacharides et al, The Superior Orbital Fissure Syndrome. J Maxillofacial Surg: 125-8, 1985 Zacharides et al, Orbital Apex Syndrome. Int J Oral & Maxillofacial Surg: 352-4, 1987 Markowitz BL, Manson PN, Sargent L, et al: Management of the Medial Canthal Tendon in NOE Fractures; the Importance of the Central Fragement in Classification & Treatment. Plast Reconstr Surg: 843, 1991

Bibliography

Bibliography

Manson P et al, Structural Pillars of the Facial Skeleton, An approach to the Management of Le Fort Fractures. Plastic & Reconstructive Surgery: 57, 1980 Manolidis S, Management of Frontal Sinus Trauma. Seminars in Plastic Surgery: 261-271, 2002 Assael LA, Atlas of Facial Fractures. OMS Clinics of N.America:Vol 11, 320-1, 1999 Osguthorpe JD, Hoang G, Nasolacrimal Injuries,Evaluation & Management. Otolaryngologic Clinics of N. America: 59-78, 1991

The End

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