Facial Traumahttp://decode-medicine.blogspot.com/ by sun yaicheng
Look at the orbits carefully, 60 - 70% of allfacial fractures involve the orbit.Exceptions: local nasal bonefracture, zygomatic arch fracture, LeFort Ifracture.Bilateral symmetry can be very helpful.Carefully trace along the lines of Dolanwhen examining the Waters view in a facialseries.
Radiographic Signs of Facial Fractures Direct Signs nonanatomic linear lucencies cortical defect or diastatic suture bone fragments overlapping causing a "double- density" asymmetry of face Indirect Signs soft tissue swelling periorbital or intracranial air fluid in a paranasal sinus
Emergency Managementand Resuscitation Airway Most urgent complicationl: Airway compromise Simple interventions first No mandible? Intubation Avoid nasotracheal intubation Aviod RSI Benzodiazepines Ketamine Etomidate Be Prepared and Be Creative
Emergency Managementand Resuscitation Hemorrhage Control Rarely develop shock from facial bleeding alone Direct Pressure LeFort Fractures Nasal hemorrhage may require A&P packing
Maxillofacial Trauma-History How is your vision? Is any part of your face numb? Are your teeth meeting normally?
Maxillofacial Trauma-Physical Exam Inspection Palpation Facial elongation Tenderness High grade LeFort (intraoral palpation) Fracture Step offs Asymmetry Facial stability Deformities and cranial nerve injury Crepitus Subcutaneous air Cutaneous anesthesia
Maxillofacial Trauma-Physical Exam Periorbital and Orbital Exam Perform early Professional Lid Retractor
Maxillofacial Trauma-Physical Exam Periorbital and Orbital Exam Look for exophthalmos or enophthalmos Pupil shape Hyphema Visual acuity Entrapment signs Raccoon sign Bimanual Palpation Test
Maxillofacial Trauma-Physical Exam Oral and Mandibular Exam Mandible deviation Teeth malocclusion Paresthesia Tongue Blade Test 95% Sensitive 65% Specific
Maxillofacial Trauma-Imaging PE detects up to 90% of fractures Plain Films: Waters CT Orbital fractures 3D images available
Maxillofacial Trauma-SpecificFractures Orbital Fractures Usually through floor or medial wall Enophthalmos Diplopia Infraorbital stepoff deformity Subcutaneous emphysema 24 % of fractures are “Blowout fracture” the arrows associated with ocular point to the fracture fragments and injury periorbital tissue which have herniated into the maxillary sinus
Lefort Classification Weakest areas of midfacial complex when assaulted from a frontal direction at different levels (Rene’ Lefort, 1901) Lefort I: above the level of teeth Lefort II: at level of nasal bones Lefort III: at orbital level
LeFort I Transmaxillary fracture runs between the maxillary floor and the orbital floor. It may involve the medial and lateral walls of the maxillary sinuses and invariably involves the pterygoid processes of the sphenoid. The floating fragment will be the lower maxilla with the maxillary teeth
LeFort II Occurs along yet another weak zone in the face, and is sometimes called a pyramidal fracture because of its shape.
LeFort III craniofacial disassociation large unstable (floating) fragment is virtually the entire face!
Mandibular Fractures Second most common facial fracture Often multiple Mal-occlusion Intra-oral lacerations Sublingual ecchymosis Nerve injury Plain films Panorex CT
Clinical Findings Facial distortion Malocclusion of the teeth Abnormal mobility of portions of the mandible or teeth
一位20歲男性騎車被貨車壓過，到院時有頭部外傷，顏面骨骨折出血，胸部及腹部鈍傷，右大腿變形，BP：80/40mmHg，HR：140/min，左側呼吸音減弱，上腹部有輪胎壓痕，下列何者為處理之順序？a.頭部電腦斷層b.腹部超音波c. 環甲膜切開術(Cricothyroidotomy)d.左側胸管插入e.大腿固定 A. c,a,b,d,e B. c,d,b,e,a C. a,d,c,b,e D. c,d,a,b,e 95 急專 E. c,d,b,a,e