Maxillofacial trauma

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Maxillofacial trauma

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Maxillofacial trauma

  1. 1. Maxillofacial Trauma
  2. 2. Etiology and Incidence <ul><li>Multisystem injury 20-50% </li></ul><ul><li>Nasal and mandibular fractures most common in community ED’s </li></ul><ul><li>Midface and zygomatic injuries most common in Trauma centers </li></ul><ul><li>25% of women with facial trauma result of domestic violence </li></ul><ul><li>Incidence of concomitant cervical spine injuries with facial fractures </li></ul>
  3. 3. Etiology and Incidence <ul><li>Older age, MVC and TBI-higher incidence </li></ul><ul><li>Facial fractures-a distracting injury? </li></ul><ul><li>Carotid artery injury </li></ul><ul><li>Blindness may occur with facial fractures </li></ul>
  4. 4. Maxillofacial Trauma
  5. 5. Emergency Management and Resuscitation <ul><li>Airway </li></ul><ul><ul><li>Most urgent complication-Airway compromise </li></ul></ul><ul><ul><li>Simple interventions first </li></ul></ul><ul><ul><li>No mandible? </li></ul></ul><ul><li>Intubation </li></ul><ul><ul><li>Avoid nasotracheal intubation </li></ul></ul><ul><ul><li>May not want RSI </li></ul></ul><ul><ul><ul><li>Benzodiazepines </li></ul></ul></ul><ul><ul><ul><li>Ketamine </li></ul></ul></ul><ul><ul><ul><li>Etomidate </li></ul></ul></ul><ul><ul><li>Be Prepared and Be Creative </li></ul></ul>
  6. 7. Emergency Management and Resuscitation <ul><li>Airway Management Options </li></ul><ul><ul><li>Awake intubation </li></ul></ul><ul><ul><li>Laryngeal Mask Airway </li></ul></ul><ul><ul><li>Fiberoptic intubation </li></ul></ul><ul><ul><li>Lateral or semi-prone position </li></ul></ul><ul><ul><li>Percutaneous transtracheal jet ventilation </li></ul></ul><ul><ul><li>Retrograde intubation </li></ul></ul><ul><ul><li>Cricothyroidotomy </li></ul></ul>
  7. 8. Emergency Management and Resuscitation <ul><li>Hemorrhage Control </li></ul><ul><ul><li>Rarely develop shock from facial bleeding alone </li></ul></ul><ul><ul><li>Direct Pressure </li></ul></ul><ul><ul><li>LeFort Fractures </li></ul></ul><ul><ul><li>Nasal hemorrhage may require A&P packing </li></ul></ul><ul><li>History </li></ul><ul><ul><li>Vision </li></ul></ul><ul><ul><li>Teeth alignment </li></ul></ul><ul><ul><li>Abuse </li></ul></ul>
  8. 9. Maxillofacial Trauma-Physical Exam <ul><li>Inspection </li></ul><ul><ul><li>Facial elongation </li></ul></ul><ul><ul><ul><li>High grade LeFort Fracture </li></ul></ul></ul><ul><ul><li>Asymmetry </li></ul></ul><ul><ul><ul><li>Deformities and cranial nerve injury </li></ul></ul></ul><ul><li>Palpation </li></ul><ul><ul><li>Tenderness </li></ul></ul><ul><ul><li>Step offs </li></ul></ul><ul><ul><li>Facial stability </li></ul></ul><ul><ul><li>Crepitus </li></ul></ul><ul><ul><li>Subcutaneous air </li></ul></ul><ul><ul><li>Cutaneous anesthesia </li></ul></ul>
  9. 10. Maxillofacial Trauma-Physical Exam <ul><li>Periorbital and Orbital Exam </li></ul><ul><ul><li>Perform early </li></ul></ul>Professional Lid Retractor
  10. 11. Maxillofacial Trauma-Physical Exam <ul><li>Periorbital and Orbital Exam </li></ul><ul><ul><li>Look for exophthalmos or enophthalmos </li></ul></ul><ul><ul><li>Pupil shape </li></ul></ul><ul><ul><li>Hyphema </li></ul></ul><ul><ul><li>Visual acuity </li></ul></ul><ul><ul><li>Entrapment signs </li></ul></ul><ul><ul><li>Raccoon sign </li></ul></ul><ul><li>Bimanual Palpation Test </li></ul>
  11. 12. Maxillofacial Trauma-Physical Exam <ul><li>Penetrating Injuries </li></ul><ul><ul><li>Occult globe penetration </li></ul></ul><ul><ul><li>Eyelid lacerations </li></ul></ul><ul><li>Nose </li></ul><ul><ul><li>Septal hematoma </li></ul></ul><ul><ul><li>CSF Rhinorrhea </li></ul></ul><ul><li>Ears </li></ul><ul><ul><li>Subperichondral hematoma </li></ul></ul><ul><ul><li>Hemotympanum </li></ul></ul><ul><ul><li>Battle sign </li></ul></ul>
  12. 13. Maxillofacial Trauma-Physical Exam <ul><li>Oral and Mandibular Exam </li></ul><ul><ul><li>Mandible deviation </li></ul></ul><ul><ul><li>Teeth malocclusion </li></ul></ul><ul><ul><li>Paresthesia </li></ul></ul><ul><ul><li>Tongue Blade Test </li></ul></ul><ul><ul><ul><li>95% Sensitive </li></ul></ul></ul><ul><ul><ul><li>65% Specific </li></ul></ul></ul>
  13. 14. Maxillofacial Trauma-Imaging <ul><li>Head, chest and abdominal trauma takes precedence </li></ul><ul><li>PE detects up to 90% of fractures </li></ul><ul><li>Plain Films </li></ul><ul><li>CT </li></ul><ul><ul><li>Orbital fractures </li></ul></ul><ul><ul><li>3D images available </li></ul></ul>
  14. 15. Maxillofacial Trauma-Specific Fractures <ul><li>Frontal Sinus/Bone Fractures </li></ul><ul><ul><li>Direct blow </li></ul></ul><ul><ul><li>Frequent intracranial injuries </li></ul></ul><ul><ul><li>Mucopyoceles </li></ul></ul><ul><ul><li>Consult with NS for treatment, disposition and antibiotics </li></ul></ul><ul><li>Nasoethmoidal-Orbital Injuries </li></ul><ul><ul><li>Lacrimal apparatus disruption </li></ul></ul><ul><ul><li>Bimanual palpation if medial canthus pain </li></ul></ul><ul><ul><li>CT face </li></ul></ul>
  15. 16. Maxillofacial Trauma-Specific Fractures <ul><li>Orbital Fractures </li></ul><ul><ul><li>Usually through floor or medial wall </li></ul></ul><ul><ul><li>Enophthalmos </li></ul></ul><ul><ul><li>Anesthesia </li></ul></ul><ul><ul><li>Diplopia </li></ul></ul><ul><ul><li>Infraorbital stepoff deformity </li></ul></ul><ul><ul><li>Subcutaneous emphysema </li></ul></ul>
  16. 17. Maxillofacial Trauma-Specific Fractures <ul><li>Orbital Fissure Syndrome </li></ul><ul><ul><li>Fracture of the orbital canal </li></ul></ul><ul><ul><ul><li>Extraocular motor palsies and blindness </li></ul></ul></ul><ul><ul><ul><li>If significant retrobulbar hemorrhage, may need cantholysis to save vision </li></ul></ul></ul><ul><li>Zygomatic Fractures </li></ul><ul><ul><li>Tripod fracture </li></ul></ul><ul><ul><ul><li>Most serious </li></ul></ul></ul><ul><ul><ul><li>Lateral subconjunctival hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Need ORIF </li></ul></ul></ul><ul><ul><li>Arch fracture </li></ul></ul><ul><ul><ul><li>Most common </li></ul></ul></ul><ul><ul><ul><li>Outpatient repair </li></ul></ul></ul>
  17. 18. Tripod Fracture
  18. 19. Maxillofacial Trauma-Specific Fractures <ul><li>Maxillary Fractures </li></ul><ul><ul><li>High-energy injury </li></ul></ul><ul><ul><li>100x gravity </li></ul></ul><ul><ul><li>Malocclusion </li></ul></ul><ul><ul><li>Facial lengthening </li></ul></ul><ul><ul><li>CSF rhinorrhea </li></ul></ul><ul><ul><li>Periorbital ecchymosis </li></ul></ul>
  19. 20. LeFort Fractures
  20. 22. Maxillofacial Trauma-Specific Facial Fractures <ul><li>Mandibular Fractures </li></ul><ul><ul><li>Second most common facial fracture </li></ul></ul><ul><ul><li>Often multiple </li></ul></ul><ul><ul><li>Malocclusion </li></ul></ul><ul><ul><li>Intraoral lacerations </li></ul></ul><ul><ul><li>Sublingual ecchymosis </li></ul></ul><ul><ul><li>Nerve injury </li></ul></ul><ul><ul><li>Plain films </li></ul></ul><ul><ul><li>Panorex </li></ul></ul><ul><ul><li>CT </li></ul></ul><ul><ul><li>Open Fractures </li></ul></ul><ul><ul><ul><li>Pen G or Cleocin </li></ul></ul></ul>
  21. 23. Body 30-40 % Angle 25-30 % Condyle 15-17 % Symphysis 7-15 % Ramus 3-9 % Alveolar 2-4 % Coronoid Process 1-2 %
  22. 24. Questions? <ul><li>Thank You! </li></ul>
  23. 25. Lecture Questions <ul><li>What portion of the mandible is most commonly fractured? </li></ul><ul><ul><li>Ramus </li></ul></ul><ul><ul><li>Coronoid process </li></ul></ul><ul><ul><li>Body </li></ul></ul><ul><ul><li>Angle </li></ul></ul><ul><ul><li>Symphysis </li></ul></ul>
  24. 26. <ul><li>Orbital fractures can cause all of the following except: </li></ul><ul><ul><li>Blindness </li></ul></ul><ul><ul><li>Motor palsies </li></ul></ul><ul><ul><li>Facial anesthesia </li></ul></ul><ul><ul><li>Enophthalmos </li></ul></ul><ul><ul><li>Hyphema </li></ul></ul>
  25. 27. <ul><li>Which of the following is/are true regarding maxillary fractures? </li></ul><ul><ul><li>Only minimal force necessary </li></ul></ul><ul><ul><li>Rarely cause CSF rhinorrhea </li></ul></ul><ul><ul><li>May cause facial lengthening </li></ul></ul><ul><ul><li>Usually the only sustained injury </li></ul></ul><ul><ul><li>All of the above are true </li></ul></ul>
  26. 28. <ul><li>The best modality for diagnosing an orbital or facial fractures is </li></ul><ul><ul><li>Plain films </li></ul></ul><ul><ul><li>MRI </li></ul></ul><ul><ul><li>CT </li></ul></ul><ul><ul><li>Ultrasound </li></ul></ul><ul><ul><li>Osteopathic palpation </li></ul></ul>
  27. 29. <ul><li>Which statement below is correct? </li></ul><ul><ul><li>Midface fractures usually have minimal morbidity </li></ul></ul><ul><ul><li>The tongue blade test is quite sensitive in assessing need for mandibular xrays </li></ul></ul><ul><ul><li>The bimanual nasal exam is crucial in possible medial orbital wall fracture </li></ul></ul><ul><ul><li>Midface fracture is an indication for nasotracheal intubation and RSI is often needed in these patients </li></ul></ul>

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