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11. Facial Bone fractures.ppt
- 1. Facial Bone Fractures Dr.Krishna Koirala
- 2. • Nasal bonesare the most common types of facial fractures ( ~ 50% of all facial fractures) –Face is specifically targeted during assaults –Nose is centrally placed and most anteriorly projecting part • Others: • Frontal bone, zygomatic, maxilla, mandible
- 3. Etiology • Road TrafficAccident • Fall injury • Assault • Sports injury • In children –‘Fall’ while playing –Child abuse
- 4. Management of facialtrauma • Manage airway, breathing and circulation • Control hemorrhage • Treat associated injuries of head, neck, cervical spine, chest, abdomen, pelvis and limbs • Wound debridement • Treatment of maxillo -facial bone injury
- 5. Examination of facialinjuries • Eyes : Palpate orbital margins especially floor • Nose − External deformity/bony crepitus − Septal hematoma/CSF leak • Middle 3rd − Palpate bony contour of face/step deformity − Surgical emphysema/Infraorbital & facial nerve deficit
- 6. • Mandible − Blood-stainedsaliva − Jaw asymmetry − Step deformity of jaw − TMJ tenderness − TMJ pain on mouth opening / Trismus
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- 8. • Type ofNasal Injury depends on direction of blow (frontal, lateral, from below) and force of blow • Divided into 3 classes (Moore 1989) • Class 1: − Green stick injury − Simple depression of nasal bone − Chevalet fracture • Class 2 : Jarjavey's fracture • Class 3 : Naso- orbito - ethmoid fracture
- 9. Depressed fracture • Mediumforce − Open book fracture (nasal septum collapses and nasal bones splay out) • Greater force − Nasal bones shattered, splaying of frontal processes of maxilla
- 10. Angulated fracture • Mediumforce Ipsilateral nasal bone fracture • Greater force B/L nasal bones and septum fracture and deviation of nasal bridge
- 11. Vertical fracture ofthe cartilaginous nasal septum due to a frontal or frontolateral blow • Mostly due to lateral trauma • Nasal bones are displaced laterally without gross depression • There is fracture of the perpendicular plate of ethmoid and the quadrilateral cartilage
- 12. Naso- orbito ethmoidfracture ( NOE) • Based on the degree of central fragment injury (Markowitz et al 1991) − Type I fractures : Single noncomminuted central fragment without medial canthal tendon disruption − Type II fractures : Comminuted fracture of central fragment, but the medial canthal tendon attached to a definable segment of bone − Type III fractures (uncommon) : Severe central fragment comminution with disruption of the medial canthal tendon insertion
- 13. • Clinical signs −Telecanthus − Telescoping of the orbit − Pig snout deformity − Positive bowstring sign
- 14. Clinical features • Externalnasal deformity • Epistaxis • Laceration of skin of nose • Edema over nasal bridge (within few hours of injury ) • Peri -orbital ecchymosis • Nasal bone tenderness • Nasal bone crepitus
- 15. Plain X-ray softtissue nasal bone lateral view
- 16. Treatment • Fractures withoutdisplacement : no treatment • Fractures with displacement : closed reduction • Open reduction required rarely for • Infection • Comminuted fracture • Failed closed reduction
- 17. Guidelines for treatmentof nasal bone fractures • Closed reduction done before edema appears (3hours) or after edema subsides (7 days) • Nasal fracture heals by 2 wks in adults and 1 wk in children. Closed reduction is to be done before healing • Healed deformities corrected by rhinoplasty or septo-rhinoplasty
- 18. Closed reduction 1. Liftnon-depressed nasal bone laterally with Walsham’s forceps 2. Lift depressed nasal bone laterally with Walsham’s forceps 3. Nasal septal fracture reduced by lifting it with Asch’s forceps 4. Both nasal bones brought into midline by firm digital pressure from outside
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- 21. Instruments used forreduction of fracture nasal bone
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- 25. Boies elevator • Boieselevator is inserted into the nostril deep to displaced nasal bone • Blade of elevator opposes thumb of surgeon placed outside the nose • Raise & depress misaligned bones to their original configuration between the thumb & elevator
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- 27. Lead plate splintingfor comminuted fractures
- 28. Rhinoplasty for healeddeformity
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- 32. Types Le Fort 1: Transverse Le Fort 2 : Pyramidal Le Fort 3 : Cranio -facial dysjunction
- 33. Le Fort 1:Transverse fracture through the maxillary sinuses, lower nasal septum, pterygoid plates Le Fort 2: Oblique fracture crossing zygomaticomaxillary suture, inferior orbital rim, nasal bridge Type 3: Fracture above the zygomatic arch, through the lateral and medial orbital walls and nasofrontal suture Le Fort 3 Le Fort 2 Le Fort 1
- 34. Le Fort 1(Guerin) fracture • Runs above nasal floor, through nasal septum, maxillary sinuses & inferior parts of pterygoid plates
- 35. Le Fort 2fracture • Runs obliquely from maxillary sinus floor to infraorbital margin, across orbital floor & lacrimal bone to nasion
- 36. Le Fort IIIfracture • Runs from medial wall of orbit to superior orbital fissure across sphenoid and zygomatic bone to zygomatico -frontal suture inferiorly to pterygoid plates • Craniofacial disjunction • Dish face deformity : Flattened and depressed face
- 37. Fracture reduction • Closedmethods − Hard palate disimpaction with Rowe’s forceps − External fixation on halo frame, box frame − Inter-maxillary fixation External Fixation Inter-maxillary fixation
- 38. • Open methods −Inter-osseous wiring − Compression plates & screws
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- 40. Mechanism of injury: Medium strength blunt trauma to eyeball
- 41. • Clinical Features −Enophthalmos − Orbital emphysema − Inferior rectus & orbital tissue get trapped in # site prevents upward eye movement diplopia − Orbital hemorrhage − Ruptured eyeball • Forced duction Test ? • CT Nose and PNS − Tear drop sign
- 42. Treatment Protocol • Approaches: Transconjunctival , transantral • Principles of surgery − Release of entrapped orbital soft tissue & inferior rectus muscle − Removal of small bony fragments & repositioning of large bony fragments − Repair of bony defect with micro-plating & biocompatible implants
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- 46. Gillie’s approach • Incisionmade 4 cm superior to zygomatic arch & posterior to temporal hairline • Periosteal elevator carried forward, between the temporalis fascia & temporalis muscle & positioned beneath zygomatic arch • Lateral traction placed on zygomatic arch
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- 49. Clinical features andinvestigations • Blood-stained saliva • Trismus • Malocclusion of teeth • Ecchymosis / hematoma on the floor of mouth • Tenderness at site of fracture • Crepitus at site of fracture • Step-deformity on palpation CT Scan of mandible
- 50. Fracture reduction • Closedmethods (Inter-maxillary fixation) − Inter-dental wiring − Arch bars and rubber bands • Open methods − Inter-osseous wiring − Lag screws − Compression plates & screws
Editor's Notes
- #50 CT Scan of mandible