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Joseph.Lex@TUHS.Temple.edu
Lecture Outline
Emergency management Facial exam Fractures
Major Minor
Causes of Mortality
Acute
Airway compromise Exsanguination Associated intracranial or cervicalspine injury
Delayed
Meningitis Oropharyngeal infections
Epidemiology
Estimated 3,000,000 facial trauma cases per year in USA Estimated 40 to 50% of motor vehicle victims have facial injury No uniform reporting or registry of cases
Functions of Face
Respiratory upper airway Visual Olfactory Mastication Cosmetic Communication Individual recognition
Management Sequence
Airway control / immobilize cervical spine Bleeding control Complete the primary survey Secondary survey
Consider NG or OG tube placement
Management Sequence
Plain radiographs if fractures suspected CT if suspect complex fractures
Management Sequence
Repair soft tissue immediately if no other injuries Delay soft tissue repair until patient in OR if surgery for other injuries necessary
Initial Management
Step 1: Airway control Oxygen for all patients May need to keep patient sitting or prone Stabilize C-spine early Large bore (Yankauer) suction available
Initial Management
Step 1: Airway control Orotracheal intubation preferred over nasotracheal if possible midfacial fracture and invasive airway needed Combitube, retrograde wire, or cricothyroidostomy if unable to orotracheally intubate
Initial Management
Step 2 : Bleeding control Can be major threat to life Use universal precautions Direct pressure dressings initially Contraindicated: blind vessel clamping
Initial Management
Step 2 : Bleeding control Rapid nasal packing may be necessary
Be sure blood is not just running down posterior pharynx
Initial Management
Step 2 : Bleeding control Rarely: emergent cutdown and ligation of external carotid artery needed to prevent exsanguination Note: Although shock in facial trauma patient is usually due to other injuries, it is possible to bleed to death from a facial injury
Airway Compromise
Blood in airway Debris in airway
Vomitus, avulsed tissue, teeth or dentures, foreign bodies
Pharyngeal or retropharyngeal tissue swelling Posterior tongue displacement from mandible fractures
Secondary Survey
Scalp Check for lacerations, hematomas, stepoffs, tenderness Bleeding maybe brisk until sutured Can use stapler for rapid closure
Secondary Survey
Ears Examine pinnae, canal walls, tympanic membranes Suction gently under direct vision if blood in canal Put drop of canal fluid on filter paper for ring sign CSF leak Assess hearing
Secondary Survey
Eyes Pupils, anterior chamber, fundi, extraocular movements Conjunctivae for foreign bodies Palpate orbital rims
No globe palpation if suspect penetration
Secondary Survey
Eyes Lid injury can leave cornea exposed
Use artificial tears or cellulose gel
Secondary Survey
Overall facial appearance Assess for symmetry, deformity, discoloration, nasal alignment Palpate forehead & malar areas
Secondary Survey
Nose Check septum for hematoma & position Check airflow in both nares Palpate nasal bridge for crepitus Check fluid on filter paper for ring sign (for CSF leak)
Secondary Survey
Mouth Check occlusion Reflect upper & lower lips Check Stenson's duct for blood Palpate along mandibular and maxillary teeth (be careful !)
Secondary Survey
Mouth Palpate along exterior of mandible Pull forward on maxillary teeth
Secondary Survey
Neurologic Skin fold symmetry at rest Motor: each division of CN-VII Sensation: 3 divisions of CN-V Sensation on tongue Gag reflex
Fracture Classification
Major Lefort I, II, III Mandibular Minor Nasal Sinus wall Zygomatic Orbital floor Antral wall Alveolar ridge
Forces Required
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures 100 g Supraorbital rim fractures 200 g
Lefort Fractures
Lefort fractures can coexist with additional facial fractures Patient may have different Lefort type fracture on each side of the face
Differentiating Leforts
Pull forward on maxillary teeth Lefort I: maxilla only moves Lefort II: maxilla & base of nose move: Lefort III: whole face moves:
Lefort I: Nasomaxillary
Horizontal fracture extending through maxilla between maxillary sinus floor & orbital floor
Crepitus over maxilla Ecchymosis in buccal vestibule Epistaxis: can be bilateral Malocclusion Maxilla mobility
Lefort I: Nasomaxillary
Closed reduction Intermaxillary fixation: secures maxilla to mandible May need wiring or plating of maxillary wall and / or zygomatic arch Antibiotics: anti-staphylococcal
Lefort III
Craniofacial dissociation Bilateral suprazygomatic fracture resulting in a floating fragment of mid-facial bones, which are totally separated from the cranial base
Lefort III
Signs and Symptoms Face lengthening: caved-in or donkey face Malocclusion: open bite Lateral orbital rim defect Ecchymoses: periorbital, subconjunctival
Lefort III
Signs and Symptoms Bilateral epistaxis Infraorbital paresthesia Often medial canthal deformity Often unequal pupil height
Lefort III
Usually associated with major soft tissue injury requiring emergent surgery for bleeding control Surgery can be delayed till edema resolves Intermaxillary fixation
Lefort III
Transosseous wiring or plating
Frontozygomatic suture Nasofrontal suture May need extracranial fixation if concurrent mandibular fracture
Antibiotics
Forces Required
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures 100 g Supraorbital rim fractures 200 g
Mandible Fractures
Airway obstruction from loss of attachment at base of tongue >50 % are multiple Condylar fractures associated with ear canal lacerations & high cervical fractures High infection potential if any violation of oral mucosa
Mandible Fractures
Signs and symptoms Malocclusion Decreased jaw range of motion Trismus Chin numbness Ecchymosis in floor of mouth Palpable step deformity
Mandible Fractures
Tongue blade test: have patient bite down while you twist. If no fracture, you will be able to break the blade.
Mandible Fractures
Treatment Prompt fixation: intermaxillary fixation (arch bars), +/- body wiring or plating
TMJ Dislocation
Can occur from direct blow to mandible Can occur spontaneously from yawning or laughing Mandible dislocates forward & superiorly Concurrent masseter & pterygoid spasm
TMJ Dislocation
Symptoms Patient presents with mouth open, cannot close mouth or talk well Can be misdiagnosed as psychiatric or dystonic reaction
TMJ Dislocation
Treatment Manual reduction: place wrapped thumbs on molars & push downward, then backward Be careful not to get bitten Usually does not require procedural sedation or muscle relaxants
Forces Required
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures 100 g Supraorbital rim fractures 200 g
Forces Required
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures 100 g Supraorbital rim fractures 200 g
Zygomatic Fractures
Tripod (tri-malar) fracture Depression of malar eminence Fractures at temporal, frontal, and maxillary suture lines
Zygomatic Fractures
Isolated arch fracture Less common Shows best on submental-vertex xray view Painful mandible movement Usually treat with fixation wire if arch depressed
Zygomatic Fractures
Tripod S & S Unilateral epistaxis Depressed malar prominence Subcutaneous emphysema Orbital rim stepoff Altered relative pupil position Periorbital ecchymosis Subconjunctival hemorrhage Infraorbital hypoesthesia
Forces Required
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures 100 g Supraorbital rim fractures 200 g
Supraorbital Fractures
Frontal sinus fracture Often associated with intracranial injury Often show depressed glabellar area If posterior wall fracture, then dura is torn
Supraorbital Fractures
Ethmoid fracture Blow to bridge of nose Often associated with cribiform plate fracture, CSF leak Medial canthus ligament injury needs transnasal wiring repair to prevent telecanthus
Orbital Fractures
Blow out fracture of floor Rule out globe injury
Visual acuity Visual fields Extraocular movement Anterior chamber Fundus Fluorescein & slit lamp
Orbital Fractures
Symptoms and signs Diplopia: double vision Enophthalmos: sunken eyeball Impaired EOMs Infraorbital hypesthesia Maxillary sinus opacification Hanging drop in maxillary sinus
Orbital Fractures
Diplopia with upward gaze: 90%
Suggests inferior blowout Entrapment of inferior rectus & inferior oblique
Questions??
Summary
Assess ABC's first Do complete exam as part of secondary survey Obtain standard X-rays and / or CT scan as indicated Decide if specialist referral and / or operative repair indicated
Summary
Arrange followup after repair to assess for delayed complications or cosmetic problems