MAXILLO-FACIAL TRAUMA

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					MEMENTO MORI
MAXILLO-FACIAL TRAUMA




        R.Drummond
        October 24, 2002
        preceptor: Carol Holmen
Overview
   General approach to facial trauma
   Epidemiology
   anatomy
   diagnostic imaging
   specific conditions
   diagnosis of facial trauma as a
    presentation of abuse
   Conclusions
General Comments

   Injuries to the face devastating to patient
   physical, emotional, occupational, sequelae
   Two presentations simple, isolated injuries clinically
           stable vs. Manifestation of severe trauma
   25% of maxillofacial trauma involves litigation
   most injuries can be picked up on thorough clinical
           assessment
   Our role is usually to diagnose not treat
   Overlap of specialists ENT, OPHTH,PLASICS,
                     NEUROSURGERY, DENTISTRY
Question 1: The single most valuable xray of the
mid-face is:

   1)Water’s view
   2)Lateral view
   3)Caldwell view
   4)Towne’s view
Question2 : Most associated injuries in cases of
maxillofacial trauma are to the:


   1)brain
   2)cervical spine
   3)chest
   4)abdomen
Question 3: Open bite may be secondary to all
except:


   1)LeFort Fracture
   2)tripod fracture
   3)mandibular fracture
   4)NEO fracture
Question 4: All of the following are true about
children with maxillo facial trauma except


   1)greater risk of lower cervical
              spine injury
   2)intracrainial injury is higher
   3)mid-face fracture higher as child
        grows
   4)non-accidental trauma should be
        considered
Triage scenario


   Two vehicle head on collision, driver and
         front seat passenger in one vehicle,
   single driver in second vehicle
   cars each going 30 m.p.h.
   all were unrestrained
   all brought to ED by EMS
   all on spinal boards
Patient 1


   5 year old child passenger of car
   windshield fractured in target pattern
   No LOC
   Large Laceration across forehead , boggy
    swelling of skin, moderate “watery” epistaxis

   HR 140 BP 90/45 RR 34 (crying) sats 100%
   GCS 15
Patient 2


   26 year old woman, was driver of the car
   face hit steering wheel... No L.O.C.
   Badly injured face, no other obvious injuries
   gasping “I have to sit up I can’t breathe”
   vitals HR 120 BP 90 /40 RR 36 Sats 89 on
    10litres GCS 14
    primary survey gurgling resps with considerable
    blood in mouth gaping wounds across forehead
    jaw is mangled with evident deformity
Patient 3


   18 year old driver of other vehicle works
         as a miniaturist painter, lost his
    bottle-bottom spectacles at scene of
    accident
   hit driver’s side window
   No L.O.C.
   HR 100, BP 120/75 RR 24 sats 98%
   GCS 15
   badly lacerated L face with deformity
    tender over zygoma diplopia numbness
    over cheek positive Marcus Gunn
Force of Gravity Necessary to Injure Face


   Nasal Bones 30 x gravity
   Zygoma 50 x gravity
   Angle of Mandible 70 x gravity
   Frontal Globellar region 80 x gravity
   Midline Maxilla 100 x gravity
   Supraorbital rim 200 x gravity
Basic Epidemiology


   Most common causes:
     MVA’s, falls, assault
   community: nose and mandible
            :MVA’s and Sports
   urban:      midface, zygoma
            penetrating and assault
   more than 60% have associated
            other injuries
MVA
Epidemiology of MaxilloFacial Injuries at Trauma
Hospitals in Ontario, Canada between 1992 and
1997
         The Journal Of Trauma, September 2000... Hogg et al


   Ontario Trauma Registry new database
   15 -22 % of trauma patients severe maxillofacial
    injuries
   2,969 patients in 12 trauma centers
   male: female 3:1
   most common cause mva’s
   26% positive BAC
   understanding causes severity temporal
    distribution effective treatment and prevention
ASSOCIATED INJURIES
TYPE OF FRACTURES
MONTH
TIME OF DAY
AGE AND GENDER
Long Term Physical Impairment and Functional Outcomes
after Complex Facial Fractures
        Plastic and Reconstructive Surgery, August 2001 Girotto,
MacKenzie et al


   Retrospective cohort study of adults 18 - 25
   265 pts with LeFort fractures compared to 242
    pts with severe general injury
   followed with several tools to assess health and
    well being
   (General Health Questionnaire, Body Satisfaction
    Scale, Social Avoidance and Distress Scale)
   hypothesis early intervention at tertiary care
    trauma center better results
   complex facial fractures represent subset of
    trauma with more longterm complications
   Obvious sequelae:
   Diplopia 56% Zygomatic fractures
   23% LeFort fractures
   20 -31% midface fractures difficulties mastication
   35% Anasomia in LeFort Fractures
   Epiphora midface fractures 25- 45 %
   facial numbness 32 -35 %



   55% of facial fractures returned to work at one year
    compared to 70% less severe facial fractures other
    general injuries
   “An appreciation of the long term physical and
    psychological sequelae of injury is essential for
    evaluating current treatment plans and to assist
    in providing appropriate counseling or referral
    to other healthcare professionals”
Triage and immediate management


   Airway management first and major priority
   be prepared for surgical airway
   clear cervical spine then let patient adopt most
    comfortable position
   caution re nasal tracheal intubation
   if RSI prep for cricothyroidectomy
   awake intubation
   ketamine a good drug
   tongue often obstructs
    Shock and Hemorrhage

    Maxillofacial Trauma seldom cause of shock
    60% association other injuries
    If shock check for other sources
    with severe facial smashes
               reduce fracture plates
    severe epistaxis hard to control : Foley
   All patients with significant facial injuries
    must be presumed to have cervical spine
    injury until proved otherwise
History


   Mechanism of injury
   blunt vs. Penetrating
   L.O.C.?
   questions:
   Do you see double?
   Are there areas of numbness on your face?
   Does your bite feel normal?
   Which areas on your face hurt?
   Does it hurt when you open your mouth and
                  where?
   Consider abuse
Physical Exam


   Inside Out and bottom up
   bird’s eye view and worm’s eye view
   Gestalt
   90% of all facial fractures can be picked up or
    suspected by careful palpation
   careful ocular exam visual acuity fields
   subconjunctival hemorrhage
   Pinpoint exam, Marcus Gunn exam
   raccoon eyes, battle sign
   halo test
   intranasal palpation test
   Allergies
   Tetanus status
Anatomy


   Vertical buttresses: nasal, frontal, and zygomatic
    maxillary give vertical stability
   zygomatic temporal buttresses horizontal support
Three Zones of Facial Anatomy


   UPPER: Superior Orbit and above Frontal Bone
   MIDDLE: Superior Orbital rim to occlusal surface
      Orbits, Nasal bones, Zygoma, Maxilla
   LOWER: mandible, teeth



   clinical exam should guide and direct radiological
    exam
FACIAL BONES
NERVES OF FACE
Diagnostic Imaging


   Standard Four Views

   Waters
   Caldwell
   Lateral
   Submentovertex

   Occlusal views
   Panorex
Waters View


   Most valuable
   prone.... Clear c-spine
   draw four lines should be parallel and smooth
WATERS VIEW
WATERS VIEW
WATERS VIEW PARALLEL LINES
Caldwell View


   Supplements Waters view
   superior orbital rim
   sinuses
   orbital region

   can see teardrop sign
   open bomb bay door sign
CALDWELL VIEW
CALDWELL VIEW
Lateral View


   Frontal Sinus
   maxillary sinus
   occasionally pterygoid plate
LATERAL VIEW
Submentovertex view


   “Jughandle” view
   Main value is to see zygomatic arch
SMV VIEW
   X-rays good screening test to guide which CT
    scan to order and level

   Ctscan most useful to grade injury and plan
    surgery
   most useful for orbital and maxillary fractures
   blowout fractures in particular

   axial and coronal
   can do 3-D reconstruction
Lefort III
DENTAL PANOREX
PEDIATRIC DENTAL PANOREX
18 year old girl playing catcher at slo-pitch
baseball game hit in forehead by baseball bat
large laceration with swelling forehead 3 min
LOC
   What to look for on exam??

   Crepitation, subcutaneous emphysema, soft
    doughy feel
   check laceration carefully
   check for csf in nose halo sign
Frontal Bone Injuries - Anatomy


   Proximity to brain, nose, orbits
   outer table thicker than inner
   dura forms inner periosteum
   intracranial injuries esp if posterior wall
   one study 89% significant frontal bone fractures
             eye problems including blindness
FRONTAL BONE
FRONTAL BONE
FRONTAL BONE #
FRONTAL BONE #
FRONTAL BONE #
Investigations


   Skull films useful
   if xray positive Ctscan
Management


   CNS or ENT consult

   ??Antibiotics

   if yes, first generation cephalosporin
   clavulin or septra

   anterior wall elevation for cosmesis
32 year old male partying at Dutch Creek
campground pitched tent on sixty foot cliff drank
twelve beer and smoked two joints got up at 4 am
to take a leak... He hit the bottom before his pee.
Four hour rescue operation in the dark. After trip
to local hospital full work up showed only large
ecchymosis and swelling over base of nose
noted to have continuous tearing left eye double
vision
   NASO-ORBITAL-ETHMOIDAL (NOE or NEO)
    FRACTURE
   Zone between cranial, orbital, and nasal cavities
   disorganization of skeletal structure
   check intercanthal distance.... Telecanthus
   intranasal palpation test
   CSF rhinorrhea
   septal hematoma
   fine cut Ctscan coronal sections
Nasal Bone Fractures


   Three questions
   Have you ever broken your nose before?
   How does your nose look to you?
   How is your breathing?
# NASAL BONES
NASAL BONE #
Findings


   Crepitus, hypermotility, edema, tenderness, deformity
   depressed vs. Laterally angulated vs comminuted
   if mechanism severe look for other injuries
   control epistaxis
   look for septal hematoma..... Drain
   are xrays necessary
   if early: reduce with simple pressure
   if late: needs operative repair
   f/u with plastics more important than x-ray
Pediatric Concerns


   Bones not fused
   can develope growth retardation
   if significant needs complete reduction
   f/u plastics in 4 days
28 year old bungee cord jumper in Australia
jumping off bridge in the dark 100 feet hit surface
of water went three feet under water... Ok that
night next day very swollen face double vision on
exam could not get left eye to look upward
BUNGEE CORD JUMPER
BUNGEE JUMPER BLOWOUT
ORBITAL BONES - what is bone 3 called??
BONES OF THE ORBIT
ORBIT: ANATOMY
ORBIT: ANATOMY
Orbital Fractures


   After life-saving measures preservation of
    eyesight next main priority
   blunt trauma to orbit or globe
   seven bones in orbit any guesses?
   frontal, zygoma,sphenoid, ethmoid, maxilla,
    palatine.....and
   lacrimal
   cone or pyramid in shape
   design feature
BLOWOUT LEFT EYE ENTRAPMENT
EOM ENTRAPMENT IN BLOWOUT
BLOW OUT TEARDROP SIGN
ORBITAL BLOWOUT
BLOW OUT AIR FLUID LEVELS
   Dangerous triad decreased field,double vision,
    decreased visual acuity
   distinguish pure from impure orbital fractures
   pure orbital fracture synonymous with Blow Out
   first called this by Smith and Regan 1957
   first described in 1844
   Ask:
   Do you have double vision?
   Do you have numbness cheek, lip, mandibular teeth

   often examiner neglects superior and lateral rim of
    orbit
   subcutaneous emphysema pathognomonic for rupture
    into maxillary sinus
PERIORBITAL EMPHYSEMA
Diplopia


   Complicated by edema, blood, temporary
    neuromuscular injury,change in orbital shape,
    third nerve palsy
   entrapped EOM does not resolve
   forced duction test

   Enophthalmosis :retraction of eye into socket
investigations


   Xray finding Caldwell
   teardrop sign
   open bomb bay door sign
   air/fluid level in maxillary sinus
   CT scan definitive
BLOWOUT
MEDIAL WALL BLOWOUT
CORONAL SLICES THROUGH ORBIT
BLOWOUT FRACTURE
Management


   Any questionable midface injury consult
    ophthalmologist
   many delay repair for two weeks
   AB if subcutaneous emphysema
   do not blow nose
   rare malignant periorbital emphysema
   lateral canthotomy
The Diagnosis and Management of Orbital Blowout
Fractures Update 2001
    Brady, McMann et al., American Journal of Emergency Medicine


     100 Blowout Fractures
     59 pure blowout fractures
     age 8 to 75
     falls, aggression, and sports
     periorbital ecchymoses, diplopia, hypoesthesia in
      V2 intraorbital emphysema
     plain xrays 13/26 false negative
     only 5 true positives
     CT 51/59 true positives
   Implants 35/55 cases
   lyophilized bovine before 1996
   controversy in 1971 and 1974
   most enophthalmosis and diplopia spontaneously resolve
   orbital floor repair dangerous



   current recommendations:
   surgery if diplopia from entrapment not gone 2 weeks
   enophthalmosis greater than 2 mm
   orbital floor greater than 50% blown out

   (unacceptable cosmetic results)
   Do not recommend plain xrays
   direct Ctscan
   cold packs x 48 hours
   use of nasal decongestant
   no ASA
   no nose-blowing
   Steroids
   broad spectrum antibiotics
   transconjunctival approach
56 year old male street person drank a little too much
MogenDavid kicked in face as he slept on heating grate
swollen left face subconjunctival hemorrhage lateral
deviation of eye
ZYGOMA FRACTURE
ZYGOMA TRIPOD #
ZYGOMA TRIPOD #
ZYGOMA TRIPOD FRACTURE
TRIPOD FRACTURE
ZYGOMA ARCH FRACTURE
ZYGOMA ARCH #
3D RECONSTRUCTION # ZYGOMATIC ARCH
Cause


   Second most common facial fracture after nasal
    bones
   tripod vs arch
   articulates with maxilla, frontal and temporal
    bones
   tripod more serious
   arch more common
What Questions to ask


   Does it hurt to open your mouth?
   Is your lower lid, cheek, teeth numb?
MASSETER MUSCLE
Findings


   Masseter attachment
   pulls bone lateral and inferior
   vertical dystopia

   ipsilateral epistaxis
   edema masks deformity
   check for symmetry
   check inside of mouth for tenderness zygomatic
    arch
Investigations


   Single Waters view
   submentovertex view
   Ctscan definitive
Management


   Rule out ocular injury
   admit tripod fracture
   OPD for arch fractures f/u for plastics
   elevated with Gilles elevation
44 year old thrown off motorcycle ruptured
spleen required 14 units PRBC’s third day in ICU
on ventilator noted to have badly swollen
ecchymotic skin around face with unusual
distortion (according to sister) massive bruising
around eyes
Maxillary Fractures


   Huge amounts of energy
   high association with other injuries
   classification system
   LeFort I,II, III IV
   usually seen in textbooks
   in practice combinations of the above
   can be “greenstick” or impacted
   they all involve malocclusion
MAXILLARY FRACTURE
LEFORT I II AND III
LEFORT I
LEFORT II
LEFORT III
LEFORT II AND III
Questions if Conscious?


   Does your bite feel normal?
   Is your lip numb?
   Does your jaw hurt? Where?

   Site of premature contact points to fracture site
   disruption of periosteum
Investigations


   Plain films not useful
   plain waters view
   any haziness or any suspicion CTScan
   2 - 3 mm coronal cuts
   if intracranial air open skull fracture
Management


   Usually given antibiotics
   does not usually in itself cause airway obstruction
   sometimes needs aggressive airway
    management
   nasal packing can distract fracture
   foley catheter with saline
   pushing fracture back into place stops bleeding
   LeFort II and greater ORIF
38 year old woman won’t make eye contact not
forthcoming how she was hurt... Cannot open or
close mouth without severe pain swollen over
angle of left jaw
Mandibular Fractures


   Fractures chin points to side of injury
   dislocation chin points away from injury
   located to symphysis, body angle,condyle or
    subcondylar area
   third most common fracture, after, nose and
    zygoma
   At least half of mandibular fractures multiple
   second fracture often distal
   open book fracture
      symphysis plus bilateral condyles
MANDIBULAR FRACTURES
MANDIBULAR #
MANDIBULAR FRACTURE
COMBINATION FRACTURE MANDIBLE
FRACTURED MANDIBLE
MANDIBLE FRACTURE
MANDIBULAR FRACTURES
FRACTURED MANDIBLE AT ANGLE
Questions:


   How is your bite?
   Does your jaw hurt?Where?
   Is your lower lip and or chin numb?
Investigations


   Tongue Depressor test
   plain films esp panorex usually adequate
Management


   Compound Fracture by definition
   needs surgery
   needs antibiotics

   24 g wire two teeth
   Barton’s bandage
# MANDIBLE REPAIRED
43 year old epileptic found post ictal (29 second
seizure) confused cannot speak properly
dysarthric mumbling cannot close mouth
   Chin deviates away from dislocation
   occ’l bilateral dislocation chin juts forward
   if trauma x-ray before re-location
   barton’s bandage immediately
   surgery if pain, spasm,, tenderness especially if
    first time
TMJ DISLOCATION
Dental Avulsions


   Three levels of injury to teeth
   enamel, dentin (yellow) pulp
   dental pulp immediate referral to dentist to avoid
    abscess
   if avulsed time is of essence
   transport under tongue in milk or saline
   gentle rinse avoid root area
   works best if re located 20 mins
   root does not survive greater than 2 hours
         once clean replace immediately
Special considerations paediatric facial #’s


   Relatively rare
   if injured: frontal bone not mid-face, not mandible
   associated injury upper c-spine not lower
    SCIWORA
   worries about post injury dysplasia not
    scientifically confirmed
   micrognathia, asymmetry some re modelling
   nasal bones a concern
   More common if child less than three
   nasal bone fracture common



   TWO COMMON ERRORS
   failure to recognize more serious facial injury
   failure to recognize septal hematoma

   at age twelve to fifteen sinuses pneumatize
   incidence of mid-face fractures pick up
   bones set quickly early f/u 4 days
   any question about injury that can lead to growth
    retardation early f/u
            Use of Antibiotics in MaxilloFacial Fractures

   “Whether one should administer antibiotics for CSF
    rhinorrhea and if so which one, is usually a decision made by
    the neurosurgeon and usually is based on personal
    preference rather than scientific data”... Emergency Medicine
    Clinics of North America
Practice Guidelines Vanderbilt University: Antibiotic
Prophylaxis in Cranio-Facial Trauma


   ICP Monitor and ventriculostomies: Ancef 1 gm iv
    prior to insertion then q8 x3 doses
   CSF leak:No prophylactic AB use
   Pneumocephaly: No prophylactic AB use
   Open-facial fractures: Clindamycin and
    gentamycin given preop and post op x 24 hours

   benefits not substantiated by literature
Awareness of Maxillofacial Trauma as a
Manifestation of Abuse to Children, Women and
the Elderly

   Child Abuse : “ The intentional physical, sexual,
    or emotional mistreatment or neglect of a child
    under the age of 18 by a parent, legal guardian or
    caregiver that results in the injury or emotional
    detriment of the child “
   1% of pediatric population



   Age 0 -5.... 17%
   6 - 14... 57%
   15 -17.... 26%



   75 % of fatalities happen to children under five years of age
   History in family background
   findings in child’s behaviour



   common facial fractures:
   dental fractures, oral bruises, oral lacerations
   mandibular or maxillary fractures
   oral burns, avulsed teeth

   dental x-rays multiple healed fractures
SPOUSAL ASSAULT


   20% Of relationships
   10 : 1 Female : Male
   most injuries to face and head

   30% of suicides
   30% of homicides

   most likely to seek help from physician
    (especially emergency physician)
   Lacerations head and face
   hair loss, fractured teeth
   fractured jaw, isolated facial fractures
   bite marks, black eyes

   injuries without explanation
Abuse of the Elderly



   Be aware of neglect
   dental caries, cheilitis poor hygiene, unkempt
    appearance

   perpetrator often direct care-giver

   caution with hostile unconcerned caregiver
   eg: inability or unwillingness to arrange
    appropriate follow-up
Question 1: The single most valuable xray of the
mid-face is:


   1)Water’s view
Question2 : Most associated injuries in cases of
maxillofacial trauma are to the:


   1)brain
Question 3: Open bite may be secondary to all
except:


   4)NEO fracture
Question 4: All of the following are true about
children with maxillo facial trauma except


   1)greater risk of lower cervical
             spine injury
   TAKE HOME POINTS

   Huge amount of force to injure face: watch for other injuries

   MVA’s major cause of injury: strategies to prevent injuries

   Major Long Term Sequelae both physical and personal
TAKE HOME POINTS

   Shock is from another system usually not face

   Complicated airway problems need immediate
    attention

   90% of fractures can be found with careful
    palpation
TAKE HOME POINTS

   Waters view overall most useful view mid face

   Panorex most useful view for mandible

   CTScan most useful modality for Orbits and
    Maxilla
                 TAKE HOME POINTS

   Frontal Bone Fracture takes lots of force check
                intracranial and eye status

   NOE fractures orbital fractures by definition

   Nasal fractures - check for and drain septal hematomas
TAKE HOME POINTS

   Orbital injury urgent referral needs Ctscan

   Zygoma fractures arch common, tripod serious

   LeFort fractures are rarely classic in presentation
TAKE HOME POINTS

   Fractured jaw chin points to side, dislocated jaw
    points away

   Immediate replacement for avulsed teeth

   Prophylactic antibiotics not necessary facial
    fractures
TAKE HOME POINTS

   Think of growth retardation in facial fractures kids

   If you see facial injuries think abuse in children,
    women, elderly

				
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