Transcript Facial Fractures - Medical Student LC

Facial Fractures
Lisa Publicover
August 2005
Outline of Lecture
• Introduction
• Skeletal Anatomy
• Fracture Patterns
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Nasal
Zygomatic
Maxilla
Blowout
Frontal Sinus and Nasoethmoidal
Mandibular
• Approach to a Suspected Facial Fracture
Anatomy
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The face is composed of 14 bones:
1.
2.
3.
4.
5.
6.
7.
8.
Mandible (1)
Vomer (1)
Maxilla (2)
Zygomata (2)
Nasal (2)
Lacrimals (2)
Palatines (2)
Inferior Nasal Conchae (2)
Image from http://face-and-emotion.com/dataface/physiognomy/cranium.jsp
The Mandible
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Lower jawbone
Strongest facial bone
Articulates with the temporal bone
Contains foramens for the passage of
nerves and blood vessels to the face
The Volmer
• A small, narrow bone
• Forms the inferior part of the nasal septum
The Maxilla
• Paired
• Form the upper jawbone
• Articulates will every other facial bone
except the mandible
• Contains the maxillary sinuses
• Forms the inferior floor of the orbits
• Contains a foramen to allow passage of
the maxillary/infraorbital nerve
The Zygomata
• Paired
• Form the “cheekbones”
• Articulate with the temporal, frontal, and
maxillary bones
• Their prominent position and shape
renders them susceptible to injury
The Nasal Bones
• Paired
• Join in the midline to form the nasal bridge
• They articulate with the frontal, maxillary,
and ethmoid bones.
The Lacrimal Bones
• Paired
• Small & Fragile
• Located in the
medial wall of each orbit
• Contains a small fossa,
which houses the lacrimal
apparatus
The Palatine Bones
• Paired
• Located posterior to the maxilla
• Form the posterior part of the lateral wall
of the nasal cavity
The Inferior Nasal Conchae
• Paired
• Located within the nasal cavity
• Project medially from the lateral walls of
the nasal cavity
Fracture Patterns
• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus & Nasoethmoid
• Mandibular
Nasal Fractures I:
Lateral Blow
• Cause: Lateral force
• Signs & Symptoms:
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Pain
Swelling
Epistaxis
Lacerations
Respiratory Obstruction
• Treatment: Emergency care, reduction &
referral if presentation is delayed.
Fracture Patterns
• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus & Nasoethmoid
• Mandibular
Nasal Fractures II:
Other
• Cause: Anterior force
• Signs & Symptoms: Similar to lateral blow
fractures
• Treatment: Require referral for treatment.
Treatment involves adequate reduction,
packing (24-48h), and fixation with a
plaster cast or splint.
Fracture Patterns
• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus & Nasoethmoid
• Mandibular
Zygomatic Fractures
• Cause: Blunt Force
• Signs & Symptoms:
– Pain
– Numbness of the cheek, infraorbital region & upper teeth
on injured side
– Eyelid swelling
– Inability to close mouth properly
– Swelling, Edema, Ecchymoses
– Flattened cheekbone
– Palpable depression at fracture site
• Treatment: Reduction & fixation
Fracture Patterns
• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus & Nasoethmoid
• Mandibular
Maxillary Fractures
• Complex, Bilateral fracture that have an unstable
“floating” fragment.
• Classified as LeFort I, II, or III based on the plane of
the fracture.
• LeFort I – Transmaxillary
• LeFort II – Pyramidal/Subzygomatic
• LeFort III – Craniofacial
Image from http://www.rad.washington.edu/mskbook/facialfx.html
LeFort I :
Transmaxillary
• The fracture occurs along the nasal and
maxillary floor
• Almost always involves the pterygoid
process of the sphenoid bone
• May involve the maxillary sinuses
• The resultant “floating” component is the
lower part of the maxilla and its teeth
LeFort II :
Pyramidal/Subzygomatic
• Result from a downward force on the nose
• The fracture runs from the peak of the
nasal bone laterally beneath the orbits.
LeFort III : Craniofacial
• Most severe
• Often associated with extensive soft tissue
injury
• Large force is necessary to cause this type
of fracture
• The resultant “floating” component is
virtually the entire face
Fracture Patterns
• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus & Nasoethmoid
• Mandibular
Blowout Fracture
• Downward displacement of the orbital floor with
protrusion of orbital contents into the maxillary
sinus.
• Caused by a force applied to the eye, which
causes an increased intraorbital pressure.
• The elevated intraorbital pressure causes a
fracture at the weakest point (posterior medial
floor)
• Treatment involves surgical repair of the defect
in the orbital floor
Fracture Patterns
• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus & Nasoethmoid
• Mandibular
Frontal Sinus & Nasoethmoid
• Caused by a force applied to the anterior
aspect of the face
• Potentially dangerous (sharp edges can
penetrate dura resulting in leakage of
CSF)
• Treatment is surgical reduction, fixation,
and repair of any damaged ligaments.
Fracture Patterns
• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus & Nasoethmoid
• Mandibular
Mandibular Fractures (1)
• Involved in ~ 2/3 of all facial fractures
• Fractures are classified as open or closed:
• Open: With a break in the skin or mucosa
• Closed: No break in the skin or mucosa
• Described as:
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Oblique
Transverse
Comminuted
Greenstick
Mandibular Fractures (2)
• Signs & Symptoms:
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Pain
Malocclusion
Excessive salivation
Dysphagia
Swelling
Crepitation
Discoloration
Deformity
Approach to a Suspected Fracture
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History
Symptoms
Physical Examination
Imaging
History
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Cause of Fracture
Degree of Force
Specific Symptoms
Time since injury
Allergies
Medications
Etc.
Physical Examination
• Symmetry/Deformity
• Lacerations/Abrasions/Ec
chymoses
• Palpable step deformities
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Orbital rims
Zygomatic arches
Nose
Frontal Bones
Mandibular borders
• Movement of dental
arches
• Fractured/Avulsed/Mobile
teeth
• Visual disturbances
• Diplopia
• Reflexes
• Extraocular muscle
function
• Acuity
• Fields
• Intranasal Inspection
• Hematoma
• Airway Obstruction
• CSF rhinorrhea
• Facial movement
(including jaw excursions)
• Facial sensation
Radiographic Examination
Structure
Mandible
Condyle/Coronoid
Ramus/Body
Condyle & Neck
Symphysis
Symphysis/Body/Ramus
Maxilla & Zygoma
Frontal & Orbital Floor
Best View
Lateral Oblique
Waters
Reverse Townes
Occlusal
Panoramic
Waters
Lateral
Caldwell
Waters
References
Grabb, W. & Smith,J. (1979). Plastic Surgery
(3rd Ed.). Little, Brown and Company:
Boston, MA
University of Washington School of
Medicine:http://www.rad.washington.edu/
mskbook/facialfx.html