2. EVALUACIÓN CLÍNICA
• Manejo de vía aérea
• Control de la hemorragia
• Lesiones traumáticas asociadas
– Lesión de columna cervical grave 2-4%.
– TCE en un 50% (lesión intracraneal 5-10%,
fractura de base de cráneo 25%).
– Lesión ocular 25-29%
3. Prioridad de la cirugía del trauma facial
• 1) Hemorragias activas
• 2) Lesiones quirúgicas craneales
• 3) Compresión medular
• 4) Lesiones viscerales
• 5) Lesiones vasculares periféricas
• 6) Cirugía ortopédica y del trauma facial
6. Trauma facial
• a. Tercio superior
– Fracturas fronto-orbitarias
• b. Tercio medio
– Fracturas de Le Fort
– Fracturas naso-órbito-etmoidales
– Fracturas cigomático-maxilares
• c. Tercio inferior
– Fracturas mandibulares
8. Le Fort
• 3 tipos con magnitud de impacto progresiva
• Todas incluyen Fx de apófisis pterigoides
• No excluyentes y combinadas
9. Le Fort
• Le Fort I: fractura horizontal sobre línea alveolar superior
(paladar flotante)
• Le Fort II: fractura piramidal
• Le Fort III: separación de los huesos de la base del cráneo
(disyunción craneofacial)
13. Le Fort III
• Disociación craneofacial
• Hueso cigomático
14.
15. FRACTURA NASO-ÓRBITO-ETMOIDAL
(NOE)
• Golpe en nariz y transmisión posterior
etmoidal (contrafuertes maxilares mediales)
• Fractura del tercio medio facial que involucra
hueso etmoides (lámina perpendicular,
papirácea y cribiforme), propios nasales y
apófisis ascendentes de maxilares.
• Es la zona de la cara con menor resistencia a
fuerzas de fractura.
16. NOE
• Clasificación de Markowitz
– Tipo I: segmento central único, sin compromiso del
canto interno.
– Tipo II: segmento central conminuto, sin compromiso
del canto interno.
– Tipo III: segmento central conminuto, con
desinserción del canto interno.
41. Rotura ocular
• Rotura de la esclera
• Sensibilidad del 56%–68%
– Signos directos:
• Alteración del contorno o volumen (múltiples planos)
• Discontinuidad esclera
– Signos indirectos
• Aumento de profundidad de la cámara anterior
• Aire o cuerpo extraño intraocular
• Mimics
42.
43.
44.
45. Cuerpos extraños
• Inorgánicos: metal, cristal (sensibilidad 50% en
< 0.5 mm) y plástico. Sin inflamación
• Orgánicos: Madera (densidad similar al aire
pero con forma geométrica) va aumentando
de densidad con el tiempo. RM!
• RM contraindicada en metálicos (más sensible
en orgánicos)
Editor's Notes
Elevado numero. Morbilidad mortalidad. Causas
Corte fino. Reconstrucciones. Partes blandas
System of facial buttresses. Three-dimensional CT images of an adult skull in frontal (a) and lateral oblique (b) orientations with color overlays show the superficial aspects of the horizontal and vertical facial buttresses and, in b, the sites of potential complications of fractures involving each buttress. The horizontal buttresses are the upper transverse maxillary (yellow), lower transverse maxillary (green), upper transverse mandibular (orange), and lower transverse mandibular (purple) buttresses. The vertical buttresses are the medial maxillary (red), lateral maxillary (blue), posterior maxillary (magenta), and posterior vertical mandibular (purple) buttresses.
La clásica clasificación de Le Fort (I, II y III ), continúa vigente con fines didácticos, ya que esta fue hecha con traumatismos de baja energía. Hoy es más frecuente fracturas panfaciales (conminutas y con compromiso de dos o más segmentos faciales) por mayor energía de impacto, o de Le Fort combinadas
Le Fort fractures. Three-dimensional CT images of an adult skull in frontal (a) and lateral (b) orientations with color overlays show the osseous facial structures that are typically affected by type I (red), type II (blue), and type III (yellow) Le Fort fractures.
The apex of the pyramid is situated at or just inferior to the nasofrontal suture. The obliquely oriented fracture extends through the medial orbital wall, orbital floor, and zygomaticomaxillary suture, but spares the zygomatic bone.
This fracture begins at the nasofrontal suture and travels laterally through the medial and lateral orbital walls and zygomatic arch
The Markowitz and Manson classification system categorizes fractures of the NOE complex according to whether the medial canthal tendon is involved, as follows: In type I NOE fractures, the medial canthal tendon is intact and connected to a single large fracture fragment; in type II fractures, the fracture is comminuted, and the medial canthal tendon is attached to a single bone fragment; in type III fractures, comminution extends to the medial canthal tendon insertion site on the anterior medial orbital wall at the level of the lacrimal fossa, with resultant avulsion of the tendon (Figs 6, 7) (14). Although the tendon itself is not visible at multidetector CT, the radiologist’s report of the degree of comminution of the medial orbital wall at the level of the lacrimal fossa may be helpful for surgical planning of medial canthal tendon repair.
Figures 6, 7. (6) Three-dimensional CT images of an adult skull with graphic overlays depict the Markowitz and Manson classification system for classifying fractures of the NOE complex: type I NOE fracture (a), characterized by a single large central fragment with attached medial canthal tendon; type II NOE fracture (b), characterized by comminution without extension to the medial canthal tendon attachment; and type III NOE fracture (c), characterized by comminution through the medial canthal tendon attachment, with resultant tendon avulsion. (7) Three-dimensional CT image of the left medial maxillary buttress in lateral oblique orientation shows a single fracture fragment that includes the lacrimal fossa at the expected insertion site of the medial canthal tendon, findings indicative of a type I NOE fracture. Fractures through the left frontal calvaria, lateral orbital rim, and zygomatic arch also are seen.
comminuted fracture of the NOE complex with telecanthus and involvement of the bilateral lacrimal fossae (arrows), findings indicative of a type III fracture of the NOE complex with medial canthal tendon avulsion. A fragment of the fractured right medial orbital wall impinges on the right optic nerve
A fracture along the medial aspect of the frontal sinus may extend into the nasofrontal duct, causing a mucocele
Impingement of the temporalis muscle or adjacent mandibular coronoid process by displaced bone fragments may lead to trismus
Because of the abundance of bacteria in the mouth, a fracture of the alveolar process is treated as an open fracture in which there is a breach of the overlying mucosa necessitating surgical débridement and prophylactic antibiotics. Potential complications of alveolar process fractures include dental root avulsion, crown or root fracture, dental intrusion or extrusion, and malocclusion
the alveolar process (magenta), parasymphyseal region (blue), body (red), angle (green), ramus (yellow), coronoid process (orange), and condyle (purple).
Trauma directo en ojo
Suelo orbitario
Hernia muscular
Nervio infraorbitario
Damage to the inferior alveolar nerve may result in anesthesia of the ipsilateral lower lip, chin, anterior tongue, and mandibular teeth.