Middle third fracture & management ih

2. FRACTURES OF MIDDLE THIRD
OF FACIAL SKELETON
• Presenter : Dr. Itrat Hussain

3. APPLIED ANATOMY

13. ETIOLOGY
ROAD TRAFFIC ACCIDENTS
ASSAULT
PROJECTILE INJURIES
OTHERS

17. CLASSIFICATION
A. #s NOT INVOLVING OCCLUSION
1. CENTRAL REGION
a. # NASAL BONE & NASAL
SEPTUM
2. LATERAL REGEION
# ZYGOMATIC COMPLEX
B. # INVOLVING OCCLUSION
1. DENTOALVEOLAR #
2. SUBZYGOMATC #s ( LF I AND LF II)
3. SUPRAZYGOMATIC #s ( LF III)
4. EXTENDED LF #s

18. LF – I FRACTURE

19. LF – II FRACTURE

20. LF – III FRACTURE

21. CLINICAL EXAMINATION

25. CLINICAL FEATURES COMMON TO
ALL LF FRACTURES
• GROSS EDEMA OF FACE
• EPISTAXIS
• DISH FACE , LENGTHNING OF FACE
• GAGGING OF POSTEIOR TEETH
• MOBILITY OF UPPER JAW
• SURGICAL EMPHYSEMA
• GUERIN’S SIGN

26. CLINICAL FEATURES OF LF I #
• SLIGHT SWELLING OF UPPER LIP
• HEAVINESS OF TEETH
• CRACKED POT SOUND ON PERCUSSION
• ECCHYMOSIS, LACERATIONS OF LABIAL MUCOSA AND
GINGIVA
• ECCYMOSIS IN BUCCAL SULCUS BENEATH ZYGOMATIC
BUTTRESS
• DISTURBED OCCLUSION
• MOBILITY OF THE UPPER JAW
• FLOATING MAXILLA
• GRATING SOUND ON ATTEMPTED MOVEMENT OF
UPPER JAW
• SOMETIMES DIASTEMA & SCISSOR BITE (MID
PALATINE SPLIT)

27. CLINICAL FEATURES OF LF II #
• STEP AND TENDERNESS AT
INFRAORBITAL MARGIN
• MOBILITY OF MIDFACE AT NASAL BRIDGE
AND INFRAORBITAL MARGIN
• ANESTHESIA OR PARESTHESIA OF
INFRAORBITAL NERVE
• STEP OR HEMATOMA AT ZYGOAMTIC
BUTTRESS
• POSTERIOR GAGGING OF OCCLUSION
• DIPLOPIA MAY BE PRESENT
• SUBCONJUNCTIVAL ECCCYMOSIS
TOWARDS MEDIAL SIDE.

29. CAMPBELL AND TRAPNELL LINES

32. CLINICAL FEATURES OF LF III #
• PANDA FACIES – FLAT NASAL BRIDGE,
PERIORBITAL ECCYMOSIS AND ROUND
EDEMATOUS FACE
• TENDERNESS AND MOBILITY AT NASAL
BRIDGE, FRONTOZYGOMATIC SUTURE
REGION, ZYGOMATIC ARCHES
• LENGTHNING OF FACE AND DISHFACE
DEFORMITY
• HYPOGLOBUS ( # LINE PASSING ABOVE
WHITNALL’S TUBERCLE)

33. • ANOSMIA (occasionally)
• ENOPHTHALMOS AND HOODING OF
EYES
• GAGGING OF OCCLUSION
• CSF RHINORRHOEA (OCCASIONALLY)
• MOBILITY OF WHOLE OF THE FACIAL
SKELETON
• FACE APPEARS WIDENED( CHEEK BONE
FLATTENING)
• TELECANTHUS

40. DASHBOARD INJURY

48. MANAGEMENT
• EMERGENCY MANAGEMENT
• DEFINITIVE MANAGEMENT

49. EMERGENCY CARE AND
STABILIZATION
• MAKE SURE THAT AIRWAY AND
CERVICAL SPINE , BREATHING AND
CIRCULATION IS ESTABLISHED ( ABC )
• STABILIZE THE # TO MAINTAIN AIRWAY
( NEED FOR TRACHEOSTOMY ?)
• ARREST HEMORRHAGE AND TRANSFUSE
IF NECESSARY FOR TISSUE PERFUSION

50. • MONITORING OF VITALS AND
NEUROLOGICAL SIGNS ( GCS)
• WITHIN 24 HRS REPAIR DEEP
LACERATIONS, TAKE IMPRESSION OF
TEETH AND TREAT LESS SEVERE
MAXILLARY #s IF NO OTHER MAJOR
INJURY IS PRESENT ( CONTROVERSY
REGARDING EARLY DEFINITIVE
MANAGEMENT OF # Vs DELAYED
TREATMENT)

51. DEFINITIVE MANAGEMENT
• DISIMPACTION AND REDUCTION OF
MAXILLA
• FIXATION OF MAXILLA

52. DISIMPACTION AND REDUCTION
OF MAXILLA
I. OPEN REDUCTION
CLOSED REDUCTION
(WITH HAND, RUBBER DAM
SHEET, IMPRESSIN COMPOUND,
ROW’S DISIMPACTION FORCEPS,
HAYTON-WILLIAM FORCEP, BIRD
CAGE TRACTION, TRACTION BY
WEIGHT)
II. IMMEDIATE REDUCTION
GRADUAL REDUCTION (BY TRACTION)

53. FIXATION OF MAXILLA
I. INTERNAL FIXATION
A. DIRECT OSTEOSYNTHESIS
BONE PLATES
MINIPLATES AND SCREWS
MICROPLATES
3-D PLATES
BIORESORBABLE PLATES
INTEROSSEOUS WIRING

54. B. SUSPENSION WIRES
FRONTAL (CENTRAL,
LATERAL)
CIRCUMZYGOMATIC
ZYGOMATIC
INFRAORBITAL
PYRIFORM APERTURE
PERALVEOLAR

55. II. EXTERNAL FIXATION
A. CRANIOMANDIBULAR
B. CRANIOMAXILLARY
SUPRAORBITAL PINS
ZYGOMATIC PINS
HALOFRAME
LEVANT FRAME
III. TRANSFIXATION WITH K-WIRE

60. FIXATION AND IMMOBILIZATION
• SUSPENSION WIRING
A. EXTERNAL
B. INTERNAL
IMF
INTEROSSEOUS WIRING
BONE PLATING

71. MANAGEMENT PROTOCOL IN MULTIPLE
FACIAL # PATIENTS
• OUTER TO INNER RING CONSTRUCTION
• TREATMENT OF MANDIBULAR #
• TREATMENT OF ZYGOMATIC #
• TREATMENT O FRONTAL #
• TREATMENT OF MAXILLA #
• TREATMENT OF NASAL #
• TREATMENT OF FACIAL LACERATIONS
• CARE OF FACIAL NERVE, LACRIMAL
APPARATUS AND PAROTID DUCT IF
REQUIRED

76. ZYGOMATIC COMPLEX #

78. CLASSIFICATION
I. #S STABLE AFTER ELEVATION
A. Arch # Only ( Medially Displaced)
B. Rotation Around The
Vertical Axis (Medially Or Laterally)
II. #S UNSTABLE AFTER AFTER ELEVATION
A. Arch # Only (Inferiorly Displaced)
B. Rotation Around Horizontal
Axis (Medially Or Laterally)
C. Dislocation En-bloc (Inferiorly
Or Medially Or Posterolaterally)
D. COMMINUTED #S

84. CLINICAL FEATURES
• SWELLING, BRUISING OVER CHEEK
• DEPRESSED MALAR PROMINENCE OR
DEPRESSION OVER ZYGOMATIC ARCH
• TRISMUS & RESTRICTED MANDIBULAR
MOVEMENTS
• STEP AND TENDERNESS AT INFRAORBITAL
MARGIN, LATERAL ORBITAL MARGIN,
ZYGOMATIC BUTTRESS
• DIPLOPIA
• PERIORBITAL ECCHYMOSIS &
SUBCONJUNCTIVAL HEMORRHAGE
• ANESTHESIA PARESTHESIA OF
INFRAORBITAL NERVE
• EPISTAXIS

85. CLINICAL FEATURES

99. MANAGEMENT
• CONSERVATIVE MANAGEMENT WITHOUT ANY
INTERVENTION
• REDUCTION
A. INDIRECT REDUCTION
1. TEMPORAL FOSSA APPROACH
2. UPPER BUCCAL SULCUS APPROACH
3. PERCUTANEOUS APPROACH
4. INTRANASAL TRANSANTRAL
APPROACH
B. DIRECT REDUCTION (CARROLL-GIRARD
SCREW

102. CARROL- GIRARD SCREW

108. STABILIZATION AND OR
FIXATION
• NO FIXATION MAY BE REQUIRED IF #
STABLE AFTER REDUCTION
• TEMPORARY SUPPORT (WITH ANTRAL
PACK, INFLATABLE BALLOON, HEAD CAP
WITH TRACTION WIRE, SILICONE
ELASTOMER WEDGE)
• DIRECT FIXATION (WITH TRANSOSSEOUS
WIRING OR BONE PLATING)
(ABSOLUTE INDICATIONS- FUNCTION, COSMESIS,
UNSTABLE #s)