Transcript Intern`s Hour Maxillofacial Trauma Preceptor: Dr. Germar BLOCK R

Maxillofacial Trauma
Preceptor: Dr. Germar
BLOCK R
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24-year-old male who sustained
traumatic injuries during a
soccer game
DOI: 3/18/2010
TOI: 7 AM
POI: soccer field
MOI:
Few hours PTC, the patient, a
soccer goalkeeper, attempted to
recover a loose ball when he was
struck in the face by an
opponent’s knee.
After contact, the patient fell to
the ground on his left side in a
side-lying position.
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(-) LOC
(-) seizure
(+) headache
(+) dizziness
(-) vomiting
(-) rhinorrhea/ epistaxis
(-) otorrhea
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(-) dyspnea
(-) chest pain
(-) abdominal pain
(-) urinary and bowel
changes
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VS: BP 130/80, HR 86, RR
20, afeb
HEAD and NECK:
 (+) R periorbital edema with
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subconjunctival hemorrhage,
OD
R facial swelling and
tenderness
(+) crepitus on R maxillary
area
(+) upper lip laceration
(-) malocclusion, able to open
mouth to 4 fingerbreaths
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HEART
 AP, DHS, NRRR, apex beat @ 5th ICS LMCL, (-)
murmur
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CHEST and LUNGS
 ECE, CBS, (-) crackles/ wheezes
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ABDOMEN
 Soft, flat abdomen, NABS, (-) tenderness
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EXTREMITIES
 PNB, FEP, (-) cyanosi/ edema
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NEURO
 GCS 15 (E4V5M6), oriented to 3 spheres
 CN intact
 Motor strength 5/5 on all extremities
 (-) sensory deficit
 DTRs 2+, (-) Babinski
 Supple neck
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Multiple Injuries 2⁰ to -- 1. R periorbital contusion with subconjunctival
hemorrhage of the R eye
 2. t/c R maxillary fracture
 r/o intracranial injury
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Upon arrival at the ER,
 A: with the athlete in the supine position, an attempt to
open the airway using a modified jaw-thrust maneuver
was performed.
 B: the breathing can be compromised as a result of blood
from ongoing facial bleeding. After blood was quickly
cleared from the face, the source of bleeding was
identified in the upper lip, which had sustained a complete
through-and-through laceration. Direct pressure was
immediately applied.
 C: blood pressure was noted to be normal, cervical spine
was secured
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CBC
Blood type
PT/PTT
Na, K, Cl, BUN, Crea
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Towne’s, Water’s, SMV
radiographs of the chest, cervical spine
 The radiographs revealed no evidence of vertebral
fracture or pulmonary disease
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computed tomography (CT) scans of the
brain and face
 The CT scans identified
fractures of the anterior,
posterior, and medial walls of
the right maxillary sinus. A
small pocket of air was
identified in the right
infratemporal fossa,
suggesting an occult fracture
of the lateral wall of the right
maxillary sinus. The initial
facial CT scan also suggested
a fracture of the floor of the
right orbit.
 The cranial CT showed no
evidence of skull fracture or
intracranial injury.
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Multiple Injuries 2⁰ to -- 1. R periorbital contusion with subconjunctival
hemorrhage of the R eye
 2. R maxillary fracture
1. Fractures of the Nasal Pyramid
2. Fractures of the Central Midface
 Le Fort Fractures
3. Fractures of the Lateral
Midface
4. Fractures of the Frontal
bone
5. Fractures of the Anterior
Skull Base
 Escher Classification
6. Fractures or dislocation of the
mandible
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Sports
Vehicular Accidents
Mauling
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Women – consider the possibility of domestic violence
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Patients with severe facial trauma:
 multisystem trauma
 potential for airway compromise
 concurrent brain injury
 cervical spine injuries
 blindness
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Primary Survey
 Airway
 Breathing
 Circulation
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Secondary Survey
Airway:
 Chin lift.
 Jaw thrust.
 Oropharyngeal suctioning
 Manually move the tongue forward
 Maintain cervical immobilization
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Avoid nasotracheal intubation
 Adverse effects:
▪ Nasocranial intubation
▪ Nasal hemorrhage
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 cricothyroidotomy
Circulation:
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Direct pressure
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Anterior and posterior nasal packing
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Packing of the pharynx around ET tube
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Place, Time, Date, Mechanism of injury
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Detailed description of the circumstances
surrounding the injury
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Allergies, other medical problems, medications,
tetanus immunizations
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Questions:
 Was there LOC, nausea/vomiting, headache? (Head Trauma
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related questions)
How is your vision?
Hearing problems?
Is there pain with eye movement?
Are there areas of numbness or tingling on your face?
Able to bite down without any pain?
Is there pain with moving the jaw?
Inspection
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Open wounds for foreign
bodies
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Facial asymmetry
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Nose for deviation, widening
of bridge
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Nasal septum for septal
hematoma, CSF or blood
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Ears for blood or CSF
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Malocclusion
Inspection
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Battle’s sign
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Raccoon eyes
Inspection
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Otorrhea, Rhinorrhea
Halo Sign
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Not sensitive
or specific but
can be used as
a preliminary
test for CSF in
blood
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Dipstick
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Beta
transferrin
Palpation
 Palpate the entire face.
 Supraorbital and Infraorbital rim
 Zygomatic-frontal suture
 Zygomatic arches
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Nose - crepitus, deformity and subcutaneous air
Zygoma along its arch and its articulations with the maxilla,
frontal and temporal bone
Mandible for tenderness, swelling
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Intraoral examination:
 Inspect the teeth for malocclusions, bleeding
 Manipulation of each tooth
 Check for lacerations
 Mandibular movements
Ophthalmologic exam
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Visual acuity
Pupils for shape and
reactivity
Eyelids for lacerations
Extra ocular muscles
Palpate around the orbits
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Examine and palpate the exterior ears
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Otoscopic examination
 Look for lacerations
 TM rupture
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Plain films
 Confirm suspected clinical diagnosis
 Determine extent of injury
 Document fractures
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CT scan
ATS, TeAna
Thorough evaluation of all wounds
All foreign bodies must be removed
Debridement
Suturing of lacerations as needed
 Minimize scarring
 Antibiotics
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Most common bone injury in
the face
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Open or closed
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Signs
 Depression or displacement
of nasal bones
 Edema of nose
 Epistaxis
 Fracture of septal cartilage
with displacement or
mobility
 Crepitus on palpation
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All nasal injuries should be
evaluated for septal
hematoma
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Untreated- result in septal
necrosis and saddle nose
deformity
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Can become infected- result
in a septal abscess
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Radiographs:
 Lateral projection
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Treatment:
 Surgical
 After reduction, nasal cavities should be packed –
“internal splinting”
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Le Fort’s classification
 Le Fort I (transverse maxillary)
 Le Fort II (pyramidal)
 Le Fort III (craniofacial dysjunction)
Low transverse
fracture of maxilla
involving palate
 Facial edema
 Mobility of hard
palate and upper
teeth
 Malocclusion
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Pyramidal fracture
with detachment of
maxilla
 Facial edema
 Epistaxis
 Bilateral periorbital
edema and
ecchymosis
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Complete disruption of attachments of facial skeleton to
cranium
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Movement of all facial bones in relation to the cranial base with
manipulation of the teeth and hard palate
 Open patient’s mouth and grasp the maxilla arch
 Place the other hand on the forehead
 Gently move back and forth, up and down - check for
movement of maxilla
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Massive edema with
facial elongation,
flattening – “Dish faced
deformity”
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Epistaxis and CSF
rhinorrhea
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Motion of the maxilla,
nasal bones and zygoma
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Open reduction and intermaxillary fixation
should be performed to establish correct
occlusion
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Followed by rigid fixation at the piriform rims
and zygomaticomaxillary buttress.
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The zygoma has 2 major components:
 Zygomatic arch
 Zygomatic body
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Two types of fractures can occur:
 Isolated Arch fracture -most common
 Tripod fracture - most serious
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Palpable bony defect
over the arch
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Flattening of the cheek
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Pain in cheek and jaw
movement
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Limited mandibular
movement
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Radiographic
imaging:
 Submental view
“bucket handle view”
- Arches may not be seen
in usual views
(anterior, lateral)
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Treatment:
 Symptomatic - surgical
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Tripod fractures consist
of fractures through:
 Zygomatic arch
 Zygomaticofrontal
suture
 Inferior orbital rim
and floor
Symptoms
 Periorbital edema
 Sensory disturbances
along the infraorbital
nerve
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Waters
Caldwell
Submental
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Coronal CT
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Treatment:
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 Symptomatic - surgical
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Isolated fracture of the
orbital floor with partial
herniation of orbital
contents
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Facial asymmetry
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Enophthalmos
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Diplopia on upward gazeimpingement of inf. Rectus
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Check for sensory
disturbances – cheek,
upper lip, lateral nasal wall
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CT scan
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Management:
Indicated for displaced fractures or for symptomatic fractures
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Uncommon
Depression of anterior
table of frontal sinus
Intracranial injuries
Dural tears
Epistaxis
CSF rhinorrhea (disruption of posterior table
of frontal sinus with dural rupture)
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Radiographs:
 Facial views should include:
▪ Waters
▪ Caldwell
▪ lateral projections
 Caldwell view best evaluates
the anterior wall fractures
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Cranial CT with bone
window
 Frontal sinus fractures.
 Orbital rim and
nasoethmoidal
fractures
 R/O brain injuries or
intracranial bleeds
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Patients with depressed skull fractures or with
posterior wall involvement.
 ENT or nuerosurgery consultation.
 Admission.
 IV antibiotics.
 Tetanus.
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Patients with isolated anterior wall fractures,
nondisplaced fractures can be treated outpatient
after consultation with neurosurgery.
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Associated with intracranial injuries
 Orbital roof fractures
 Dural tears
 Mucopyocoele
 Epidural empyema
 CSF leaks
 Meningitis
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2nd most commonly fractured facial bone
Signs and symptoms
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Malocclusion of teeth
Tooth mobility
Intraoral lacerations
Pain on mastication
Bone deformity
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Mandibular pain
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Malocclusion of the teeth
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Separation of teeth with
intraoral bleeding
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Inability to fully open
mouth
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Preauricular pain with
biting
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Positive tongue blade test
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Radiographs:
 Panorex
 Plain view: PA, Lateral and a Townes view
Treatment:
 Nondisplaced fractures:
 Analgesics
 Soft diet
 Dent/ORL surgery referral
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Displaced fractures, open fractures and fractures
with associated dental trauma
 Urgent oral surgery consultation
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All fractures should be treated with antibiotics and
tetanus prophylaxis.
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Antibiotics
Pain management
Suture the upper lip laceration.
The facial fractures are nondisplaced and do
not require surgery. These facial fractures
should be followed for evidence of healing.