Clinical features: Periorbital edema and ecchymosis Hypesthesia of the infraorbital nerve Palpation may reveal step off Concomitant globe injuries are common
Plain films including the waters, submental and caldwell views. Can demonstrate the fracture and evaluate the zygomaticomaxillary complex, but a Coronal CT of the facial bones will best show involvement and the degree of displacement. Picture: CT 3-D. The fracture lines involved in a tripod fracture are demonstrated in this 3-D reconstruction.
Maxillofacial consultation Nondisplaced fractures without eye involvement Ice and analgesics Delayed operative consideration 5-7 days Decongestants Broad spectrum antibiotics since the fracture crosses into the maxillary sinus. Tetanus Displaced tripod fractures usually require admission for open reduction and internal fixation
LeFort II: Pyramidal fracture which includes a fracture through: Maxilla Nasal bones Medial aspect of the orbits
Lefort III fractures also known as craniofacial dissociation(separates the face from the cranium) involves fractures through the maxilla, zygoma, nasal bones, ethmoid bones and the bones of the base of the skull.
Emergency care for all these fractures involves airway maintenance, with Intubation or cricothyrotomy if necessary. Airway compromise is possible with any of these fractures but probably more common with LeFort II and III fractures. CSF rhinorrhea is uncommon in LeFort I fracture but is often seen in LeFort II and III fractures. If CSF rhinorrhea is present or intracranial air is seen on X ray or an open skull fracture is present, the patient should be admitted and place in a head elevated position (40-60 degrees) if possible. Prophylactic antibiotics are often given in these patients (Rocephin) though it has not been shown to prevent meningitis or brain abscess. Patients with maxillary fractures also have significant epistaxis which requires nasal packing. Operative intervention may be needed if bleeding doe not resolve with packing alone. Look for associated injuries, especially intracranial, spinal, thoracic and abdominal. Incidence of blindness is high for LeFort II and III fractures so it is important to get opth. consultation. Patients with Complex maxillary fractures require admission for open reduction and internal fixation.
These fractures manifest clinically with mandibular pain, tenderness and malocclusion. A step off in the dental line or ecchymosis to the floor of the mouth are often present and is highly suggested of a mandibular fracture. Patients are unable to fully open their mouth. Patients may have preauricular pain with biting when there is a fracture of the condyle. Picture 1: The open fracture line is evident clinically. There is slight mal-alignment of the teeth. Picture 2: Hemorrhage or ecchymosis in the sublingual area is pathognomonic for an mandibular fracture.
Nondisplaced fractures: Analgesics Soft diet oral surgery referral in 1-2 days Displaced fractures, open fractures and fractures with associated dental trauma Urgent oral surgery consultation, these patients are usually admitted, These patients either need closed reduction with occlusion fixation or open reduction. All patients with mandibular fractures should be treated with antibiotics and tetanus prophylaxis. Antibiotics of choice are PCN, clindamycin or a 1 st generation ceph.
Patients present with the inability to close an open mouth. Other associated symptoms include pain, discomfort and facial swelling near the TMJ. Unilateral dislocation results in deviation of the mandible to the unaffected side. Bilateral dislocation causes the mandible to be displace anteriorly. Picture: TMJ Dislocation Note the asymmetric jaw deviation toward the unaffected side. Always consider the possibility of an associated underlying fracture or cervical spine injury.
The mandible can be dislocated in the anterior, posterior, lateral and superior plane. Anterior dislocation is the most common and occurs when the condyle is forced in front of the articular eminence. Anterior dislocation occurs in up to 70% of the normal individuals but can be spontaneously reduced by the patient. Once the jaw is dislocated, muscular spasm, particularly the temporalis and lateral pterygoid muscles tend to prevent reduction. Dislocations are most frequently bilateral, but they also can be unilateral.
Reduction may be attempted in closed anterior dislocations without fracture. A short acting muscle relaxant (Versed) helps to decrease muscle spasm. An analgesic may also be considered. The patient should be seated. Facing the patient the examiner places his or hers thumbs in the patients mouth, over the mandibular molars as far back as possible. The fingers should curve beneath the angle and the body of the mandible. The examiner applies downward and backward pressure with his or hers thumbs until the condyle slides back into the articular eminence. When the dislocation is bilateral, it may be easier to relocate one side at a time. If reduction is successful, the patient should be able to close his or her mouth immediately. Post reduction films are not usually required unless the procedure was difficult or traumatic. Complications from the reduction are unusual and include iatrogenic fracture or avulsion of the articular cartilage.
Oral surgery should be consulted in patients who are found to have either an open dislocation, superior, posterior or lateral dislocations, non – reducible dislocation or a dislocation associated with a fracture.
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