Transcript Maxillofacial Trauma

Maxillofacial Trauma
Dr. Yael Moussadji
Feb 8, 2007
Objectives
To review a general approach to facial
injuries
To review specific bony injuries of the
face
To discuss general wound repair
principles and management of soft
tissue injuries of the face by anatomic
location
Epidemiology
Result from intentional violence (assults – 33%) and
unintentional (MVC’s – 50%, falls, sports – 10%)
The overall incidence of fractures in facial trauma patients is
37%
Alcohol abuse increases the likelihood of facial fracture, so have
a high index of suscpicion
Airbags and seatbelt requirements have decreased the severity
and incidence of facial injury, but they remain common among
riders of other motorized vehicles including ATVs and
motorcycles
Facial injuries are a common presentation for victims of
domestic violence (one quarter of all women who present to the
ED with facial injury) and child abuse
Associated Injury
Associated injuries are common and include brain injury (25%),
C-spine injury (6%), basal skull fractures, chest injuries (29%),
abdominal injuries (38%), and extremity fractures (33%)
Isolated facial fractures are uncommon – only 11% of patients
with facial injury will not have brain, chest, or abdominal injuries
Common associated nerve injuries include facial paralysis (CN
VII), blindness (CN II), diplopia (CNIII), deafness (CN VIII)
Minor damage to the dura can also occur with fractures
involving the frontal sinus, nasal bones, and midface, resulting
in CSF leaks
Airway Management
Recognize the facial trauma patient as a potentially
difficult airway and prepare alternatives before
proceeding; try to stay 1-2 steps ahead!
Be cautious with timing and use of paralytics; awake
and fiberoptic intubation may be the best alternatives
when dealing with distorted anatomy
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The use of minimal IV sedation and topical anesthesia
allows the EP to perform laryngoscopy without committing to
oral intubation; if the cords are visualized, you have the
option to intubate or perform RSI knowing you can access
the cords
Use nasal packing first (if there is time) to slow down
hemorrhage
Overview
Force of gravity required for fracture
Nasal (30)
 Zygoma (50)
 Angle of the mandible(70)
 Frontal (80)
 Midline maxilla (100)
 Midline mandible (100)
 Supraorbital rim (200)
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General Approach
Assess visual acuity and for the presence of
diplopia (binocular vs monocular)
Sensation of the face should be checked in
all three trigeminal branches
The patient should be asked about
malocclusion
A standard set of facial films includes the
Waters (occipitomental view) which is best for
maxillary, maxilla and orbital fractures, and
the Caldwell (occipitofrontal) view which
shows the ethmoid and frontal sinuses
Frontal Sinus Fracture
Forces involved and proximity of brain make
these fractures high risk for brain injury and
other facial fractures
The key distinction to make is the integrity of
the posterior sinus wall
Anterior wall fracture can be fixed on a nonurgent basis; these patients can have their
wounds closed, be given prophylactic
antibiotics, and referred for outpatient repair
If a posterior wall fracture exists, presume a
dural tear exists; admit to neurosurgery
Orbital Fractures
Implies a significant mechanism of trauma; 40% are ultimately
diagnosed with significant globe pathology including globe
rupture, and up to 77% have other facial fractures
Classified as pure (only orbital floor) or impure (extending into
orbital rim)
Patients with pure orbital fractures are 3 times as likely to have
concomitant ocular injuries (5.6% vs 2.0%) than patients with
impure fracures
Patients without an orbital fracture are twice as likely to have
globe pathology (in allcomers with blunt orbital trauma)
The object striking the eye must have a radius of <5cm to
produce a blowout fracture (fist)
Blowout fractures most commonly involve the floor, then the
medial, lateral, and superior walls
Clinical Findings
Diplopia on upward gaze, subcutaneous emphysema,
enophthalmos*, palpable step-off, and anesthesia in the infraorbital nerve distribution
Numbness is more commonly detected on the upper lip
Subcutaneous or intraorbital air indicates a medial wall fracture
with direct connection from the sinus to the orbit; the patient
should be instructed not to blow their nose
If air accumulates in the orbit it can cause occlusion of the
central retinal artery from increased orbital pressure; patients
will complain of a sudden loss of vision
A lateral canthotomy or aspiration of the air can prevent
permanent vision loss
Imaging and Managment
Plain films are only diagnostic in 8%
CT is 100% accurate and demontrates fat or
soft tissue protruding into the maxillary sinus,
bony fragments, and blood in the maxillary
sinus
Fluid in the maxillary sinus with a mechanism
is a blowout fracture until proven otherwise
Outpatient management is the general rule
Most surgeons wait 1-2 weeks before
attempting repair
Nasal Fractures
The nose is the most commonly fractured bone in the face,
comprising 45% of all facial fractures
Can be thought of as simple or complex
Simple involves only the nasal bones, and complex involves
other facial bones
Simple nasal fractures do not need imaging
Diagnosis is clinical based on crepitus, pain and tenderness,
epistaxis, obstruction, ecchymosis, and deformity
Most EP’s will not attempts reduction in the ED since perception
of deformity is based largely on the edema present
If indicated, you can use cocaine for anesthesia and perform
closed reduction by exerting firm quick pressure toward the
midline with your thumbs
Patients can be discharged to follow-up within 4-7 days IF
NEEDED (deformity or obstruction)
Septal Hematoma
Occurs with cartilage fractures and results from
collection of blood beneath the perichondrium
If left untreated, septal hematomas can cause
permanent damage by infection of necrosis of the
septum
Septal cartilage is dependent on blood supply from
the perichondrium, and elevation of the
perichondrium reduces blood supply; pressure from
the hemotoma worsens the ischemia
Irreversible damage can occur in 72 hours and result
in saddle nose deformity, retraction, voice changes,
or constant nasal obstruction
Management
Can usually be seen with an otoscope,
appearing as a bluish or purple swelling on
the septum (grapes)
The should be incised, drained and packed to
prevent reaccumulation
Prophylactic antibiotics (keflex) should be
prescribed, and patients should be rechecked
in 24-48 hours
Outpatient ENT consultation is recommended
Parotid Gland or Duct Injury
The parotid duct is 7cm long and courses parallel to
the jaw; it is found on the line from the lower ear to
the corner of the mouth
It exits the anterior parotid gland superficial to the
masseter muscle before piercing the buccinator
muscle and entering the oral cavity at Stenson’s duct
Parotid duct injuries occur in only 0.2% of facial
traumas, but the consequences of missed injuries
can be severe
Have a high index of suspicion with any lacerations to
the cheek and fractures of the mandible or zygomatic
arch
Anatomy
Management
After direct examination of the wound,
milk the parotid gland and look for blood
at Stenson’s duct (just inside the cheek
at the level of the upper second molar)
Give prophylactic antibiotics
(ceftriaxone 1g) and consult ENT
Facial Nerve Injury
The danger zone is bordered by a line from
the lateral canthus to the corner of the mouth,
and from the zygomatic arch to the angle of
the mandible; any wound or trauma in this
area is at significant risk for facial nerve injury
Must examine all five branches: temporal,
zygomatic, buccal, mandibular, cervical
Lifting the forehead and brow, opening and
shutting the eyes, smiling and frowning, and
shrugging the shoulders accomplish this
Maxillary Fractures
The maxilla comprises the middle third of the face,
and functions to support mastication; it also houses
the maxillary and ethmoid sinuses
It can therefore withstand large vertical forces, but is
vulnerable to lateral or anterior forces
These high energy injuries are known as Le Fort
fractures, and once the butress of the maxilla begins
to break, it fractures on three recurring lines of
weakness
It is rare when a pure fracture pattern exists; most
midface fractures are combinations
Le Fort I
Involves the maxilla
only at the level of the
nasal fossa
Usually occurs from a
downward blow on the
upper alveolar ridge
Separates the body of
the maxilla from the
lower portion of the
pterygoid plate and
nasal septum
The nose does not
move with the midface
Le Forte II
Also called a
pyramidal fracture
Fracture of the
maxilla, nasal
bones, and medial
orbits (like a Le
Forte I involving the
nose)
Nose moves freely
with the maxilla
Le Forte III
Craniofacial
dysjunction; the face is
no longer connected to
the skull
The maxilla, zygoma,
nasal bones, ethmoids
and bones of the cranial
base are all fractured
The entire face can be
moved independently of
the skull
Zygoma Fractures
Two varieties: arch fractures (more common)
and tripod fractures (more serious)
Isolated arch fractures are best seen using
the submental vertex (bucket handle) view
which isolates the arches
60% of arch fractures are displaced, and 45%
of patients complain of trismus (fracture
fragment impinges on the coranoid process)
They do not require admission, but will most
likely require surgical repair
Tripod Fractures
Combination of intraorbital rim fracture,
diastasis of the zygomaticofrontal suture, and
disruption of the zygomaticotemporal junction
of the arch
The bony fragment is usually depressed and
pulls the lateral canthus away from the eye
giving it a tilted appearance
50-90% of patients will have infraorbital
anesthesia, 12% will have diplopia
Admit to plastics
Maxillary Sinus Fractures
The walls are not very strong, and isolated
fractures can occur from direct blows to the
face
Patients complain of facial pain, but may not
have swelling
Plain films or CT will show an air fluid level in
the maxillary sinus
In isolation, can be discharged with
prophylactic antibiotics and outpatient follow
up with ENT
Mandible Fractures
Second most commonly fractured facial bone
The condyle is the most frequently fractured (36%),
followed by the body (21%) and angle (20%)
The “U” shape of the mandible makes the likelihood
of multiple fractures high (46%); the fracture site may
be distant from the actual site of impact
Condylar fractures can be associated with fractures
of the temporal bone and TM rupture, and can be
difficult to detect on plain films
Mandible Fractures
Clinical features
Complaints of malocclusion, trismus, facial
assymetry, and sublingual ecchymosis
Fractures are often open inside the mouth, and any
intraoral or gingival laceration need to be detected
In some cases the only evidence of an open fracture
is bleeding around the teeth
Have the patient grasp a tongue blade between the
teeth and resist while the examiner twists the blade
Patients with fractures will open their mouths against
resistance, while those without can hold enough
pressure until the blade breaks; this has a 95%
sensitivity for mandible fractures
Management
Any patient with evidence of an open
fracture should be admitted to IV
antibiotics (Pen G or clinda)
Antibiotics reduces the rate of infection
from 50% to 5%
For patients with closed fractures,
outpatient follow-up with plastics is
appropriate
Mandible dislocations
Can dislocate with or without trauma
Traumatic dislocations require imaging before
reduction to r/o condylar fracture
Atraumatic dislocations can occur from increased
masseter muscle tone, TMJ laxity, EPS, laughing,
yawning, vomiting, taking a large bite, dental work
Dislocation is usually bilateral but can be unilateral,
and anterior dislocation is most common
Anterior dislocation is commonly followed by spasm
of the temporalis and lateral pterygoid muscles which
holds the mandible in place and resistant to reduction
Clinical features
Patients complain of pain anterior to the
tragus, have difficulty speaking, and
may complain of malocclusion
Physical exam will show an open mouth
that cannot be closed, palpable
preauricular depression, and
mandibular deviation opposite to the
side of the dislocation
Reduction
Can be accomplished with patient seated with head
against the wall and examiner facing patient, or
patient supine and examiner standing at the head
Examiners thumbs are placed inside the patients
mouth on the surface of the molars with fingers
wrapped around the angle and body of the mandible
Downward and backward pressure is applied
The reduction is complete when the patient is able to
close their mouth
Management
Patients can be discharged with
instructions to eat a soft diet, not open
the mouth wider than 2cm for 2 weeks,
and to support their jaw when they yawn
NSAIDS for analgesia, and outpatient
follow up in 2 weeks
Wound Repair of the Face
Primary Closure & Bite Wounds
Nearly all facial wounds can be closed by primary closure
Dog bites to the face can be closed provided that wounds are
aggressively irrigated and debrided as needed; use of antibiotics
is up for debate since the infection rate is only 1.4% without
Cat bites could be closed if required for cosmetic reasons,
although most recommend not closing (usually puncture wounds
with higher infection rate)
Repair of human bites to the face is safe; primary close after
irrigation and debridement and a 1 week course of antibiotics
yields a 90% rate of complete healing at time of suture removal
Close clean facial wounds less than 24 hours old
Refer lacerations that involve the eyelid margins, nerves or
other deep structure injuries, deep foreign bodies, ear wounds
with significant cartilage damage, large flaps, tissue loss
Anesthesia
Use small gauge needles (25-27g) unless nerve
block is being performed (23-25g)
Injecting pH balanced anesthetic subcutaneously
(buffered 1% lidocaine) will significantly reduce pain
Max dose of lidocaine is 300 mg for a 70 kg adult, or
500 mL of lidocaine with epinephrine (30 mL 1%
plain, or 50 mL 1% with epi)
Lidocaine has a rapid onset and lasts 30-60 minutes
Bupivicaine has a slower onset of action and lasts 48 hours
Facial Nerve Blocks
Forehead
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Nerve blocks of the supraorbital nerve are easy to
perform and give total anesthesia of the forhead
when done bilaterally
Find the supraorbital foramen (near midline) and
insert a 1.5 inch needle parallel to the eyebrow
just above the bone
Inject 2-3 mL along the needle tract
A hematoma may form and cause subsequent
swelling and ecchymosis of the upper lid
Facial Nerve Blocks
Midface
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An infraorbital nerve block anesthetizes the lower
lid, medial cheek, upper lip, and lateral nose
Intraoral approach is less painful
Pretreat oral mucosa with viscous lidocaine, then
insert a ¾ inch needle to the hub toward the
infraorbital foramen
Insertion is through the gingival-buccal margin just
above the maxillary canine tooth
Inject 2-3 mL at foramen or 3-5 mL in a fan across
the area
Facial Nerve Blocks
Lower face
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A mental nerve block provides good anesthesia of
the lower lip and chin
Helpful for lip lacs that cross the vermillion border
Locate the mental foramen midway between the
upper and lower edges of the mandible 2.5 cm
from the midline
Pretreat mucosa with viscous lidocaine, then
insert a ¾ inch needle in the gingival-buccal
margin below the lower canine
Inject 1-2 mL of anesthetic
Wound Closure &
Follow-up
Subcutaneous sutures should be 4-0 or 5-0, and skin should be
closed with 6-0 non-absorbable
Place sutures 1-3 mm apart, 1-2 mm from the wound edge;
space deep sutures as widely as possible
A thin layer of antibiotic ointment applied after closure cuts
infection rates in half
Wounds on the forehead and chin are suited to closure with tape
Similarly, wound adhesives are as good as sutures, staples, and
tape for simple lacs under no tension; wound strength is
equivalent to sutures at 7 days (not during first 4 days) and
cosmetic outcome is comparable
Sutures should be removed at 4-5 days (7-10 in scalp), and
reinforced with tape for a further 7-10 days
Scalp Closure
There are 5 anatomic layers of the scalp (skin,
superficial fascia, galea, subaponuerotic connective
tissue, periosteum); the first 3 layers are fused as an
outer layer which contains the blood supply
For quick closure in heavily bleeding wounds, use
staples or a 3-0 suture taking deep bites through
skin, SC fascia, and galea
Wounds that gape involve the galea, which should be
closed (serves as anchor for frontalis muscle
resulting in distorted facial expression)
Forehead Lacerations
Deep wounds require closure for
approximation of frontalis muscle fascia
Large periosteal defects should also be
closed to prevent adhesion of skin to skull
(use 5-0 or 6-0 absorbable for deep sutures)
Use judgement; excess deep sutures can
lead to increased scarring
Simple lacerations can be closed using fine
suture and by placing sutures close to the
wound edge; align major forehead wrinkles
Eyebrow & Eyelid Repair
Don’t debride tissue – excision removes hair follicles
and creates alopecia
Irrigate lightly with saline
Line up edges of eyebrow to ensure brow margins
are aligned correctly
Wounds that cross the lid margin are best left to
ophthalmologist since they are at high risk of
eversion or inversion
Deep lid lacerations in the medial aspect of the upper
or lower lid are at high risk for involvement of
canalicular system or lacrimal duct; both are repaired
surgically
Nasal Lacerations
Complicated by relatively unforgiving skin; even a 6-0
suture may tear through the skin which has minimal
laxity
If wounds require debridement, best left to plastics
Skin over nondisplaced fractures can be closed
normally; cartilage repair is seldom indicated and is
usually well approximated with skin closure alone
Mucosal surfaces should be closed with absorbable
suture to cover exposed cartilage
Cheek & Chin Lacerations
Mucosal part of through and through lacs can
be left open if < 2 cm, but should be
approximated loosely with 5-0 gut if larger;
treat prophylactically with antibiotics
Before closure of cheek wounds assess for
parotid duct or gland injury and facial nerve
injury
Chin lacs are good candidates for closure
with tape or dermabond
Ear Wounds
The two major problems are cartilage injury and
hematoma formation
Cartilage is avascular and requires contact with the
skin for its blood supply
The goal of repair is to place the skin back in contact
with the cartilage
Deep sutures in the cartilage are no necessary if the
skin can be easily closed
However, if placing sutures in the cartilage use 5-0 or
6-0 vicryl (cartilage tears easily)
Place deep sutures only on prominent landmarks or
ridges; any deep suture is a potential risk for infection
Perichondral Hematomas
Common as a result of blunt trauma
Requires evacuation to prevent permanent
cartilage loss
Left untreated, produces “cauliflower ear”
Drain through a small incision, then place
pressure bandage for 24 hours
It is not unusual for hematomas to
reaccumulate and require multiple aspirations
Oral Trauma
Accurate realignment of the vermillion border is the critical step
in lip repair
Nerve blocks are the technique of choice for anesthesia
Irrigation only for removal of gross debris
Simple lacs can be closed with 6-0 non-absorbable suture and
mucosal injuries with 6-0 or 5-0 absorbable (non-absorbable is
sharp and irritating)
Through and through lip wounds should be closed in three
layers: deep muscle (ocularis oris), skin, and mucosa
Tie extra knots on the mucosal surface because they are
frequently worked loose
Up to 25% of the lip can be lost without significant deformity,
except the upper lip beneath the nose and the commissures
Tongue & Mucosal Lacerations
In most cases, sutures are not required for adequate healing;
both areas heal quickly with minimal infection
Exceptions are mucosal wounds > 2 cm or gaping lacerations,
which can form scar tissue that reduces function and interferes
with speech
Deep tongue wounds may still be left with a permanent cleft
even after healing
Sutures are recommended for any wound on the edge of the
tongue, through and through injuries, wounds that bisect the
tongue, large flaps, or for bleeding control
Place a 4% soaked gauze over the tongue before injecting
lidocaine and use 4-0 or 5-0 absorbable with buried knots
Discharge instructions consist of a soft or liquid diet, and mouth
rinses with diluted peroxide for 2-3 days