Transcript Facial Trauma

Composed mainly of the frontal bone,
temporal bones, nasal bone, zygomas,
maxilla, and mandible.
 Ethmoid, lacrimal, sphenoid bones
contribute to inner portion of orbits
 Upper third - above superior orbital rim
 Middle third (midface)- superior orbital
rim down through maxillary teeth
 Lower third - mandible

Maxillofacial
Trauma
Patient
evaluation

History

Physical exam

Other systems:
- Airway
- Circulation
- CNS (GCS)

Orbit

Nasal airway

Dental occlusion

Neurovascular

Contusion

Avulsion

Laceration
(loss of soft tissue – penetrating trauma)
First, inspect face for deformity and
asymmetry
 Enophthalmos, proptosis, ocular integrity,
ocular movements
 Nasal septum for position, integrity, and
presence of septal hematoma
 Epistaxis or CSF rhinorrhea

Complete neurological exam must be
performed on any patient with
suspected facial trauma
 Sensation - test all 3 major branches of
the trigeminal nerve
 Motor function - assess facial nerve by
having patient wrinkle forehead, smile,
bare teeth, and close eyes tightly

Palpation of facial structures - the
infraorbital and supraorbital ridges,
zygoma, nasal bones, lower maxilla, and
mandible
 Assess for tenderness, bony deformities,
crepitus, . . .
 Malocclusion or step-off in dentition may
be sign of mandibular fracture

Should focus on bony integrity, fluid-filled
sinuses, herniation of orbital contents,
and subcutaneous air
 Overall status of the patient, physical
exam findings, and the clinician’s initial
impression determine timing and nature
of imaging ordered

Traditionally the mainstay in the
radiographic evaluation of facial trauma
 Standard plain film facial series: Waters
(occipitomental), Caldwell
(occipitofrontal), and lateral views
 Panoramic films are used to best
evaluate mandibular fractures


Offers a viable, cost-effective alternative to
plain films

Very helpful in the evaluation of facial
trauma when facial edema, lacerations,
other injuries, or altered level of
consciousness limit usefulness of clinical
exam
Limited role of MR in evaluation of facial
trauma due to insensitivity of MR to
fractures
 Used to provide complimentary
information to CT in the evaluation of the
eye and its associated structures

Most common site
of facial trauma
due to location
 May be displaced
medialy, laterally
or posteriorly
 Requires control of
epistaxis and
drainage of septal
hematoma, if
present


Class 1 - frontal or frontolateral trauma
- vertical septal fracture
part

- depressed or displaced distal
of nasal bones
Class 2 - lateral trauma
- horizontal or C-shaped septal
fracture
- bony or cartilaginous septum
fracture

Class 3 - high velocity trauma
- fracture extends to ethmoid
labyrinth
- bony septum rotates posteriorly
- bridge collapse
- upturned tip, revealing nostrils
- depressed nasal bones pushed
up
under frontal bones
- apparent inter-ocular space
widening
Diagnosis:
- physical exam (asymmetry,
deviation, epistaxis, swelling, . . .)
 Radiography:
- do not have a role in management
 Timing:
- before 10 days to 2 weeks
- within two hours after injury


Managements: (closed & open
reduction)

Complications:
- septal hematoma
- CSF leakage
- ophthalmologic compl.


Tripod fracture:
zygomaticofrontal
suture,
zygomaticotemporal
suture, and
infraorbital foramen
Present with flatness
of the cheek,
anesthesia in the
distribution of the
infraorbital nerve,
diplopia, or palpable
step defect




Le Fort I – maxilla
Le Fort II – maxilla,
nasal bones, and
medial aspects of
orbits (pyramidal
disjunction)
Le Fort III – maxilla,
zygoma, nasal
bones, ethmoids,
vomer, and all
lesser bones of the
cranial base
(craniofacial
disjunction)
Usually in
combination

Fractures of the orbital floor may occur with
orbital wall fractures or as an isolated injury.

When the orbital floor, being the weakest
area, herniation of orbital contents down
into the maxillary sinus may occur (hanging
drop sign).

Patients may present with enophthalmos,
impaired ocular motility, diplopia due to
entrapment of the inferior rectus muscle
within the fracture fragments, and
infraorbital hypoesthesia.

Orbital Fractures
› Usually through
›
›
›
›
›
floor or medial wall
Enophthalmos
Anesthesia
Diplopia
Infraorbital stepoff
deformity
Subcutaneous
emphysema

This child presented with diplopia
following blunt trauma to the right eye.
On exam, he was unable to move his
right eyeball up on upward gaze.


A: Orbital blowout fracture with displacement of the floor
(arrow), distortion of the inferior rectus, and herniation of
orbital fat through defect. Arrowhead indicates medial
fracture.
B: Note opacified left anterior ethmoid air cells and
displaced medial orbital fracture (arrowheads).

Frontal Sinus/Bone Fractures
›
›
›
›

Direct blow
Frequent intracranial injuries
Mucopyoceles
Consult with NS for treatment, disposition and
antibiotics
Nasoethmoidal-Orbital Injuries
› Lacrimal apparatus disruption
› Bimanual palpation if medial canthus pain
› CT face

Orbital Fissure Syndrome
› Fracture of the orbital canal
 Extraocular motor palsies and blindness
 If significant retrobulbar hemorrhage, may need
cantholysis to save vision

Zygomatic Fractures
› Tripod fracture
› Arch fracture
 Most common
 Most serious
 Outpatient
repair
 Lateral subconjunctival hemorrhage
 Need ORIF
 Mandibular
Fractures
› Second most common facial
fracture
› Plain films
› Often multiple
› Panorex
› Malocclusion
› CT
› Intraoral lacerations
› Sublingual ecchymosis› Open Fractures
› Nerve injury
 Prophylactic Ab.

Simple
 Greenstick fracture (rare, exclusively in children)
 Fracture with no displacement (Linear)
 Fracture with minimal displacement

Displaced fracture

Comminuted fracture
Extensive breakage with possible bone and soft tissue
loss

Compound fracture
Severe and tooth bearing area fractures

Pathological fracture
(osteomyelities, neoplasm and generalized skeletal
disease)
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
They can be vertically or horizontally in
direction

They are influenced by the medial
pterygoid-masseter “sling”
 If the vertical direction of the fracture favours the
unopposed action of medial pterygoid muscle, the
posterior fragment will be pulled lingually
 If the horizontal direction of the fracture favours the
unopposed action of messeter and pterygoid muscles in
upward direction, the posterior fragment will be pulled
lingually

Favourable fracture line makes the reduced
fragment easier to stabilize
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

Note fractures in left angle and right body of
mandible
Multiple fractures are present more than 50% of
the time and are usually on contralateral sides
Facial trauma is defined as injury to the soft
tissues of the face (including the ears) and
to the facial bony structures.
 May result in hemorrhage and airway
obstruction accompanied by multisystem
involvement (as many as 60% of patients
have associated injuries)
 Evaluation includes history, physical exam,
and diagnostic imaging


Reduction of fragments in good position

Immobilization until bony union occurs
These are achieved by:


Close reduction and immobilization
Open reduction and rigid fixation
Other objective of mandible fracture
treatment:

Control of bleeding

Control of infection
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No treatment
 Soft diet
 Maxillomandibular fixation
 Open reduction - non-rigid fixation
 Open reduction - rigid fixation
 External pin fixation
 Lag screw


Arch bars
▶ IMF prior to rigid fixation
▶ For the purpose of close
reduction
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TMJ ank.
 Pediatric
 Dental root
 Inf. Alveolar N.
 airway

Facial N.
 Lacrimal ap.
 Foreign body
 Borders & margins injury
(Vermilion border- nasal ala- eyelidshelix)
