Transparency, Recognition and the role of eSealing - Ildiko Mazar and Koen No...
merin facial fractures a topic in ENT residency
1. MODERATOR – DR G M PUTTAMADAIAH
PRESENTER- DR MERIN BOBBY
23/3/2017
1
FACIAL FRACTURES AND CSF
RHINORRHOEA
2. Layout
2/27/2024
2
Introduction
facial bones
Facial Buttresses
Causes for facial fractures
Primary care-maxillofacial trauma
Types of facial fractures :
Nasal fractures and management
Mandible fracture and management
LeFort I,II,III and management
Zygomatic fractures and management
Orbital blow out and management
CSF rhinorrhoea and management
3. INTRODUCTION
3
Face is important for a number of reasons
First impression of the person
Holds and supports the eyes, nose and mouth
Vision, respiration, speech and swallow.
4. Facial skeleton can be roughly
divided into
4
Upper third
constituted by
frontal bone
Lower third
constituted by
mandible
Middle third /mid
face constituted by
maxilla
5. FACE IS COMPOSED OF 15 BONES
5
UNPAIRED
Mandible
Vomer
ethmoid
PAIRED
Nasal
Lacrimal
Inferior Nasal Conchae
Palatine
Maxilla
Zygoma
6. BIOMECHANICS OF THE FACIAL
SKELETON
6
The midface has many fragile bones that could
easily be crushed when subjected to strong forces.
They are surrounded by thicker bones lending it
some strength and stability. = butresses
vertical buttress -lateral
frontozygomatic area and down across the
strong bone of the zygomaticomaxillary area.
-The medial buttress
frontonasal region and down across the
maxilla junction to encompass the thick bone
of the piriform aperture.
7. Horizontal buttresses:
1. Frontal bar
2. Infraorbital rim &
nasal bones
3. Hard palate &
maxillary alveolus
Interconnect and
provide support for the
vertical buttresses.
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8. 1.Causes of facial fractures
Accounts for 10% of all accident and
emergency dept cases
Motor vehicle accidents
Assault/Domestic violence
Falls
Sports- related incidents
Pathological
Work- related incidents
Warfare
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9. APPROACH TO THE PATIENT WITH
TRAUMATIC INJURY OF THE FACE
9
History
Physical Examination
Imaging
Primary care
10. HISTORY OF TRAUMATIC EVENT
10
What was the mechanism of
injury?
RTA/Is the injury the result
of blunt or penetrating
trauma?
Are there any associated
thermal or chemical
injuries present?
12. RADIOGRAPHIC EVALUATION
12
X ray of facial bones/CT scan
Include facial skeleton in any CT scan
All patients- chest, cervical spine and pelvic radiograph
13. PRIMARY CARE
13
1. Airway- evaluate and secure the airway
2. Breathing- make sure there is adequate ventilation
3. Circulation- control sources of blood loss
4. Disability- assess level of consciousness and neurological
dysfunction (Use of Glasgow coma scale- impending intracranial
complication)
5. Exposure- ensure all other injuries are identified
Maxillofacial injuries usually -DANGEROUS
threaten the airway
Cause profuse hemorrhage
Associated with neck injuries
CSF rhinorrhoea- high level naso-ethmoid or maxillary fracture
CSF otorrhoea- temporal bone fractures
14. 14
SECONDARY SURVEY- exclude other injuries & categorize extent
of facial injury
Soft tissue injuries noted
Visual acuity and ocular movements
Facial nerve function
palpate the skull ,other bones for #
Dental occlusion, maxillary or mandibular instability
15. 2.Classifaction of facial
fractures
15
Based on Location
Nasal fracture
Maxilla
LeFort I
LeFort II
LeFort III
Blowout orbit
Zygomatic
Mandibular
Frontal Sinus & Nasoethmoid
16. 2.FRACTURE PATTERNS
16
Nasal
Maxilla
LeFort I
LeFort II
LeFort III
Blowout orbit
Zygomatic
Mandibular
Frontal Sinus & Nasoethmoid
17. NASAL FRACTURE
17
Nose is the most prominent
facial bone .
(osteocartilagenous framework)
Consequently Most frequently
fractured bone.
39% of all facial fractures
(Lundin 1972)
Min force for #-25-75 lb/in2
18. Nasal bone:
A thick superior portion and a thin inferior portion. The
intercanthal line demarcates these two
Most # occur in the lower half of the nasal bone.
NATURE OF INJURY
Lateral impact., the nose is displaced away from the
midline
head-on trauma, the nasal bones are pushed up and
splayed
both cases, the septum is often fractured and displaced.
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19. TYPES OF NASAL FRACTURE
19
DISPLACEMENT
LATERAL displacement:
m.c nasal #(66%)
Also easily injures the septum because the junction
between the septal cartilage and crest of maxilla is weak.
20. Extent of deformity
20
A 5-point grading system has been developed
for the extent of lateral deviation of the nasal
pyramid:
grade 0: bones perfectly straight
grade 1: bones deviated less than half of the
width of the bridge of the nose
grade 2: bones deviated half to one full width
of the bridge of the nose
grade 3: bones deviated greater than one full
width of the bridge of the nose
grade 4: bones almost touching the cheek.
21. TYPES OF NASAL FRACTURE
21
FRONTAL DISPLACEMENT: fracture of the lower portion of the nasal bone
tends to widen the nasal bridge , causing it to become splayed out
More severe trauma to this area may comminute the nasal bones.
The upper lateral cartilage become separated from the nasal bone.
INFERIOR DISPLACEMENT: septal fracture or dislocation
- often the caudal edge of the septum is displaced off the nasal spine and crest of
the maxilla into one of the nares.
22. TYPES OF NASAL BONE FRACTURES
3 classes depending on degree of damage and management
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MURRAY 1989
CLASS I FRACTURES
Class I fractures do not cause gross
displacement (Green stick variety ).
The fractured segment maintains
position because of its attachment to the
upper lateral cartilage
The fracture line runs parallel to the
dorsum of the nose and naso maxillary
suture.
There may be tenderness and crepitus over
nasal bone
The nasal septum usually not involved
Radiological evidence+/-
23. 2/27/2024
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CLASS II FRACTURES
These fractures cause a significant amount of
cosmetic deformity.
In this group not only the nasal bones are
fractured, the underlying frontonasal
process of the maxilla is also fractured. The
fracture line also involves the nasal septum.
The precise nature of the deformity depends
on the direction of the blow sustained.
A frontal impact may cause comminuted
fracture of nasal bones causing gross
flattening and widening of the dorsum of the
nose.
A lateral blow -#perpendicular plate of
ethmoid, and is characteristically C shaped
(Jarjaway fracture of nasal septum).
the ethmoidal labyrinth and the adjacent
orbit are usually intact.
24. 24
CLASS III FRACTURES: Naso orbito ethmoid
fracture
The most severe nasal injuries encountered.
caused by high velocity trauma.
PIG face apperance i.e. foreshortened saddled nose & nostrils
facing more anteriorly
Causes the perpendicular plate of ethmoid to rotate & quadrilateral
cartilage to fall backwards.
May be associated with telecanthus , lacrimal duct and nasolacrimal
duct injury .
25. 25
Two types of naso ethmoidal fractures have been recognized by
RAVEH:
Type I: The perpendicular plate of ethmoid is rotated and the
quadrilateral cartilage is rotated backwards causing a Pig
Snout Deformity of the nose. The nose appears foreshortened
with anterior facing nostrils. The space between the eyes
increase (Telecanthus), the medial canthal ligament may be
disrupted from the lacrimal crest.
Type II: Here the posterior wall of the frontal sinus is disrupted
with multiple fractures involving the roof of ethmoid and orbit.
Anterior skull base is sometimes involved. Since the dura is
adherent to the roof of ethmoid, fractures in this region causes
tear in the dura causing CSF rhinorrhoea. Pneumocranium
and cerebral herniation may complicate this type of injury.
26. 2/27/2024
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Fractures of nasal
septum
Types :1}Chevallet
fracture: results from
blow from below. it
runs vertically from
anterior nasal spine
upwards to the
junction of bony and
cartilaginous dorsum
of nose.
27. 27
2}Jarjaway fracture:
C shaped, result from
blow from front.
Fracture line starts just
above the anterior
nasal spine and runs
horizontally
backwards involving
bony septum
Associated with nasal
Class II #
28. CLASSIFICATION OF NASAL FRACTURES
28
Strance and Robertson 1979
Type I- Nasal tip
Type II-Nasal dorsum,septum and maxilla ,lacrimal
bone and ethmoid bone
Lateral-oblique forces-
Type I- Ipsilateral nasal spine
Type II- Contralatrral nasal bone and septum
Type III- Nasal spine , frontal process of maxilla and
lacrimal
29. SYMPTOMS/SIGN
29
IMMEDIATE:
Bleeding
Swelling/ Deformity of
the nose and bridge
Pain
Crepitus
DELAYED:
Subconjunctival hemorrhage
Circumorbital ecchymosis
Diplopia
Epiphora
Enopthalmos
Nasal obsruction
Numbness
Pain along the fracture line
Deformity
30. DIAGNOSIS
30
HISTORY: of nasal trauma and
bleeding suggests a probable
nasal fracture.
Photographic documentation
of nasal fracture is an
important part of the medico
legal.
CLINICAL EXAMINATION:
external nose for tenderness,
mobility
Anterior Rhinoscopy:
Bleeding
Septal
disarticulation/dislocation
Septal haematoma
CSF leak
EYES : Check for the following
Position of the eyeball –
exopthalmous
/enopthalmes
Movement of the eyeball
Diplopia , visual acuity
31. MANAGEMENT
31
INVESTIGATIONS:
nasal bone lateral view,Waters
view ,caldwell view
CT SCAN :for more severe facial
injury
Samples of any watery rhinorrhoea
must be collected in those with
suspected cerebrospinal fluid (CSF)
leak and tested for beta-2
transferrin.
32. MANAGEMENT
32
GOALS:
Restore satisfactory
appearance.
Restore nasal airway
patency.
By replacing septum in the
midline.
Preserve nasal-valve
integrity.
Prevent complications:
(stenosis , columellar retraction
& saddle deformity, septal
perforation )
PLAN : immediate
Topical nasal
decongestants nasal
drops
Analgesics
Antibiotics
Nasal packing for
epistaxis
33. MANAGMENT
33
Soft tissue swelling can be misleading .A very significant
number of patients do not require any active treatment.
Many do not have a nasal fracture / fracture may not be
displaced.
Reassurance is all that these patients require.
The indications for surgical intervention in the acute
phase are
significant cosmetic deformity and
nasal obstruction caused by a septal haematoma.
34. Fracture REDUCTION
34
TYPES: Closed Reduction
Open Reduction
TIMING OF REDUCTION:
1.Immediate reduction
2.In case of swelling-most authors agree that reduction is performed
within 3 to 7 days.
The usual recommendation is that closed reduction be carried out
with in 5-7 days for children and 5-10 days for adults.
PRINCIPLE: To mobilize the fragments first by increasing and then
decreasing the degree of deformity.
35. CLOSED REDUCTION:
35
INDICATION
All class 1 and most class 2 fractures.
Old fractures :the bones are fixed and osteotomies
are necessary to release the fragments before
manipulation.
These should be performed cautiously to avoid the
risk of extension into the orbit or other bones.
36. 36
LA/GA
LA-reduces cost & convenience
Intranasal& external:
4% of xylocaine and 1:10000
epinephrine used on the cotton
pledgets.
Inj 2% lidocaine wit 1:100000
epinephrine along nasomaxillary
groove, infraorbital nerve,
Infratrochlear nerve
ANESTHESIA
37. 37
INSTRUMENTS:
(a)Howarth's elevator
(b) Ashe's forceps (septum):
(c) Walsham's forceps (nasal
bones)elevators.
(d)Boies nasal fracture elevator
(e)Mayo hemostat with rubber tubing
Ashe or walsham forceps can be
inserted one blade in each nostril or
one blade inserted in the nose under
the nasal bone and the other placed on
the overlying skin.
38. 38
The distance from the nostril rim to the
nasofrontal angle is measured and the
instrument is inserted to a point about 1cm
less then measured distance.
Nasal structures are manipulated with forceps
in one hand and other hand helping to exert
digital pressure to set the bone into suitable
position.
The septum can be stabilized with splints
suture and gauze packing.
39. An external dressing of paper tape ,2 inch wide
orthopedic plaster and an external layer of tape is
applied.
Splints are removed 10 days after the operation.
It is advisable to refrain from contact sports for at
least six weeks.
39
40. UNSTABLE FRACTURE
40
For depressed tip that are unstable despite closed reduction
techniques, Kirschner (K) wires can be used.
The wire is inserted under fluoroscopic guidance into the
depressed fragment as well as neighboring uninvolved bone
(maxilla or frontal bone), and the wires are screwed together
externally to maintain the position.
The external wire can be covered by dressings or plaster to
protect the wires from disruption and the patient from injury.
The wires are removed after two weeks
41. OPEN REDUCTION
41
INDICATION :
Verwoerd :
Infraction of the nasal dorsum
Bilateral fractures with dislocation of the nasal dorsum
and significant (preexistent or recent) septal deformity
Fractures of the cartilaginous pyramid, with or without
dislocation of the upper laterals.
42. 42
METHOD:
1. Septum can be approached through
a hemitransfixation incision on the
side of dislocation.
2. For Nasal bone: intercartilagenous
incision :The dorsal skin is elevated
off the upper lateral cartilages and
the periosteum is elevated from the
nasal bones.
3. Incision in the piriform aperture
provide access to the lateral
fracture lines.
The cartilaginous segments are
exposed and reduced
Radical resection of cartilage or
bone is avoided to preserve
support and limit fibrosis and
contracture
43. 43
Comminuted depressed
nasal fracture
Reduction requires elevation
of the nasal bones anteriorly
and repositioning
Or a through and through trans
nasal wiring to support and hold
the fragments in place.
44. 2.FRACTURE PATTERNS
44
Nasal
Zygomatic
Maxilla
LeFort I
LeFort II
LeFort III
Blowout orbit
Mandibular
Frontal Sinus & Nasoethmoid
46. 46
4 processes:
a) Frontosphenoid
b) Maxillary process
c) Orbital process – orbital floor
d)Temporal process- Along with the zygomatic
process of the temporal bone forms the zygomatic
arch.
47. Types of zygomatic fracture
Second common facialZygomatic complex fracture
– separate of zygoma from its
articulations=Tripod fracture- seperation from
1. Fronto-zygomatic suture
2. Infra-orbital rim
3. Zygomatico-maxillary buttress
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48. 48
2. Zygomatic arch fracture – fracture of zygomatic arch
in isolation
tends to break at its weakest point- posterior to
zygomatico-temporal suture
Medial displacement impinges on coronoid process-
limits opening and closing of mouth
49. CLASSIFICATION
49
• SCHJELDERUP CLASSIFICATION: Classified based on rotation
about vertical & horizontal axes
TYPE I – Displaced zygomatic bone hinged on the maxillary
and frontal attachments.
TYPE II –Displaced zygoma hinged on the maxillary
attachment.
TYPE III –Displaced zygoma hinged on the frontal attachment.
TYPE IV –Grossly comminuted
50. Classification of zygomatic fractures
(Henderson, 1973)
Type 1 – Undisplaced fracture
Type 2 – Arch fracture only
Type 3 – Tripod malar fracture (Fronto-Zygomatic
suture intact)
Type 4 – Tripod malar fracture (Fronto-Zygomatic
suture distracted)
Type 5 – Pure blowout fracture
Type 6 – Orbital rim fracture
Type 7 – Comminuted and other fractures
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52. In 1985, Rowe changed his 1968
classification and gave more clinical
significance by dividing fractures into
stable and unstable varieties.
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53. Group A: Stable fracture—showing minimal or no
displacement and requires no intervention.
Group B: Unstable fracture—with great displacement
and disruption at the frontozygomatic suture and
comminuted fractures. Requires reduction as well as
fixation.
Group C: Stable fracture—other types of zygomatic
fractures, which require reduction, but no fixation.
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54. 54
Depending on water’s
view
Gp 1- undisplaced #
Gp2 – isolated displaced
arch #
Gp3 – unrotated
displaced body#
Gp4- medially rotated
body
Gp5- laterally rotated
body
Gp 6- complex body #
55. SIGNS & SYMPTOMS
55
1. EYE:Subconjuctival haemorrhage,
ecchymosis
2. Eye movement restricted in upward
gaze, diplopia- orbital floor
dehiscence
3. Step deformity of infra-orbital margin
4. CHEEK: Reduced zygomatic
prominence
5. Arch #- limited mouth opening,
palpable depression
6. Sensation of cheek altered-
zygomatico-temporal or
zygomaticobuccal nerve
7. Pain
57. 57
CONCOMITTANT BLOW OUT #
forced duction test –the tendon of the inferior rectus
muscle is grasped by forceps through the conjunctiva
and an attempt made to rotate the eye upwards.
Resistance to free movement indicates that there is a
mechanical obstruction due to—
1.Herniation of periorbital fat.
2. Impingement of bone fragments upon fat and muscle.
3.Fibrous tissue formation and adhesions.
58. MANAGMENT
58
X-RAY PNS WATER’S VIEW
SUBMENTOVERTEX - "JUG
HANDLE"
CALDWELLS VIEW
TOWNES VIEW
CT SCAN – The best evaluation of
suspected zygomatic and orbital
fracture
3D reconstuction CT
60. MANAGMENT
60
Minimally displaced # managed conservatively
Displaced #-reduction with or without fixation
Prophylactic antibiotic
Anesthesia –under GA
61. Gillies temporal approach-
61
This method was originally introduced
by GILLIE et al 1927.
Incision down to temporalis fascia,
incised and elevator passed down on
the temporalis muscle so that its tip lies
just under the fracture. The bone is then
elevated.
-Bristow’s elevator
-Rowe’s zygomatic elevator
ADVANTAGES OF GILLE’S METHOD
Quick method
Decreased possibility of facial nerve
damage
No visible scar
Further fixation can be performed at the
time of operation if necessary.
63. 63
3. Poswillo hook-
intersection of
vertical line along
lateral orbital margin
& horizontal line
along inferior margin
of nose, hook is
inserted & zygoma
lifted back
64. Buccal sulcus or keen approach-
64
This technique was developed by
Keen in 1909 .
The major advantage is the avoidance
of external scar.
It can be used for both zygomatic
complex and arch fracture.
INCISION -1cm incision is made in the
mucobuccal fold beneath the
zygomatic buttress of the maxilla.
elevator is passed behind zygomatic
body to elevate #
65. 65
Unstable fractures- inferior
displacement, rotation
around the horizontal
axis, diastasis at
frontozygomatic
suture
Open reduction &plating
frontozygomatic
suture, zygomatic arch,
infra-orbital margin
70. CLASSIFICATION
70
BY RENE LEFORT 1901.
LE FORT I-
Syn-Low level fracture
,transverse fracture ,horizontal
fracture, transmaxillary,
Guerin’s #
Floor of the nasal cavity,
through the nasal septum,
maxillary sinuses & inferior
part of medial and lateral
pterygoid plates.
71. 71
LE-FORT 2:
Pyramidal fractures ,subzygomatic
fractures
Separation of the maxilla and the
attached nasal complex from the
orbital and zygomatic structures.
Results from a force delivered at a
level of the nasal bones in superior
direction.
The fracture line occurs along the
nasofrontal suture lacrimal
bone across the infra- orbital
rim in the region of the
zygomatico-maxillary suture
above the canine eminence
inferiorly and distally along the
lateral antral wall, but at a higher
level than Le Fort type I across
the pterygoid plate at its middle.
infraorbital nerve involved.
72. 72
LE- FORT 3:
High transverse fracture
,suprazygomatic fracture
,craniofacial dysjunction.
Arch of zygoma also broken
The fracture line courses
through the
zygomaticotemporal and
zygomaticofrontal sutures
lateral orbital wall inferior
orbital fissure fractures the
pterygoid plate at its base
Medial wall of orbit - superior
orbital fissure - across greater
wing of sphenoid medially
to the naso-frontal suture .
Posteriorly #line runs inferior
to optic foramen across lesser
wing of sphenoid to
pterygomaxillary fissure and
sphenopalatine foramen
73. SIGNS & SYMPTOMS
73
1. Epistaxis
2. Facial edema
3. Surgical emphysema
4. Lengthening of face
5. Floating palate & teeth in Le- Fort 1
6. Circumorbital ecchymosis- panda face/
raccoon eye
7. Infraorbital anaesthesia Lefort II
8. Flattening of the cheek
9. CSF Rhinorrhoea
10. Anterior open bite- le-fort 2 & 3
11. Haematoma at junction of hard & soft palate
12. Blindness
75. MANAGMENT
75
INVESTIGATIONS
CT SCAN-
CT –Clearly has an advantage in diagnosis when
injury involves the para nasal sinuses ,orbital wall
and soft tissue.
3D scan –most advantageous in case of sever
facial trauma.It has been shown to have
increased accuracy in the region of the vertical
maxillary buttress.
MRI – typically not helpful in acute bony trauma
to the face.It is typically performed 48 hr after
trauma..
80. MANAGEMENT
80
o Le-fort 1
Disimpaction :Posterior
impaction of maxilla- pulled
forwards using index &
middle finger
Reduction- digital pressure
& traction on arch bars or
interdental wires
Maxilla fixation
1. Intermaxillary fixation-
Not displaced
84. EXTERNAL FIXATION
84
Maxilla is fixed by attaching a
fork to the teeth with a silver
cap splint. This in turn is
anchored to'stable bone'
above the fracture.
Types: halo frame ,levant
frame
Advantage: extremely rapid
Can be applied in the intensive
care unit
Make fine adjustment during
the initial phase of bony
healing in the first 2weeks.
85. MANAGMENT
85
lOPEN REDUCTION AND
INTERNAL FIXATION :
Lefort II,III also I
Miniadaptation plates with
multiple screws can be
made use for the fixation.
Incision:through the
gingivobuccal incision.
The infraorbital rim needs to
be reduced and fixed in Le
Fort 2,3.
86. Various skeletal incisions for exposure of
midface skeleton are follows:
1. Supraorbital eyebrow incison
2. Subciliary incision
3. Median lower eyelid incision
4. Infraorbital incision
5. Transconjunctival incision
6. Zygomatic arch incision
7. Transverse nasal incision
8. Vertical nasal incision
9. Medial orbital incision.
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86
87. 87
A, Repair of a split maxilla by the placement of a plate across the fracture in the
anterior maxilla.
B, Direct placement of a plate along the palatal fracture.
C, Similar to B, this demonstrates the use of a box plate to lend greater stability to
the palatal fracture repair
88. Diagrammatic representation of Le Fort II fractures reduction
88
Rigid fixation with
miniplates.
defect can be repaired
with a bone graft.
The bone graft is
lagged to the bone on
either end so that the
bone graft itself
functions as the rigid
fixation device
89. ORBITAL ACCESS:
89
Incision Advantage Disadvantage
Transconjuctival Good exposure,
aesthetic
Slight risk of entropion
Transconjunctival with
cantholysis
Excellent exposure Risk of lid malposition
Transconjunctival with
transcaruncular
Excellent exposure of
medial orbital wall
Technically difficult
Lower eyelid Straight forward to
execute
Risk of increased scleral
show, ectropion.
90. FRACTURE PATTERNS
90
Nasal
Maxilla
LeFort I
LeFort II
LeFort III
Blowout orbit
Zygomatic
Mandibular
Frontal Sinus & Nasoethmoid
91. MANDIBULAR FRACTURE
91
ANATOMY : The anatomic
components of the mandibular
include-
Symphysis
Para Symphysis
Body
Angle
Coronoid Process
Condyle
Alveolus
92. 92
Mandible #- direct & indirect
force
# occurs at sites of potential
weakness :
Parasymphysis- long root of
lower canine
Angle of mandible- unerupted
tooth
Condylar neck- slender anatomy
Can # at multiple sites-
parasymphysis (direct) &
condylar neck (indirect)
body
angle
93. FRACTURE PATTERNS
93
OPEN FRACTURE: (COMPOUND) – Communication with
external environment ,either through skin or mucosa .Any fracture
involving a tooth bearing segment is an open fracture by definition.
CLOSED FRACTURE (SIMPLE) –No communication with external
environment.
COMMINUTED- Multiple segments of bone are shattered , crushed ,
or splintered
GREENSTICK –Incomplete and only involves one cortex.
PATHOLOGIC- A fracture occurring from pre-existing disease that
has structurally weakened the bone is pathologic.
96. 2. Unfavorable (unstable) :Fracture
line and vector pull of the muscle cause
displacement.
The mandibular fracture has 3 forces
acting upon it-compression ,tension &
torsion.
The muscle responsible for the vertical
displacement are masseter ,temporalis,
and medial pterygoid.
Horizontal displacement can be
caused by the lateral pterygoid torsion
by the mylohyoid ,digastrics and
geniohyoid..
96
97. SIGNS & SYMPTOMS
97
Deviation of the mandible
:change in facial contour or
arch (Step deformity)
Asymmetry of lower dental
arch
Dental malocclusion
Haematoma in buccal sulcus
tenderness
Crepitus of fractured segments
Anaesthesia of lower lip
98. FRACTURE OF CONDYLAR NECK
98
Trismus
Tenderness over TMJ
Deviation of jaw to injured
side on opening mouth
Deviation of jaw to uninjured
side at rest
Malocclusion
100. 100
Fractures in left angle & right
body of mandible
Multiple fractures are present
more than 50% of the time and
are usually on contralateral
sides of the symphysis
102. CLOSED REDUCTION
102
INDICATIONS:
undisplaced fractures & no neural deficits
unilateral condylar fractures.
Intermaxillary fixation
DENTAL ARCH intact:-
Two adjacent teeth brought in contact-
Eyelet wires
Leonard button -modification an eyelet wire
with a small metal disc instead of a loop
Teeth as biological bone pins.
104. INTERMAXILLARY FIXATION
104
Advantages
1. Simple
2. Easy to handle ,before
planned open reduction
& internal fixation
3. Reduce pain
4. Reduce Bleeding from
bone ends
Disadvantages
1. Airway compromise
2. Dietary restrictions
3. Difficult to thread wire
through tight interdental
points
4. Fixation could be
inadequate
105. 105
INCOMPLETE DENTAL
ARCH
ARCH BARS:
Strip of metal wired to each
jaw using several individual
teeth.
May be prefabricated using
a model made from a
preoperative dental
impression
Types: Jelen,Erich pattern ,
German silver notched
106. 106
INTERMAXILLARY
BONE PINS:
A monocortical screw is placed
through the mucosa between
the canine and first premolar
on each side and jaw.
The screws are then wired
together or connected with
elastic bands.
Path of the screw should enter
bone and avoid the roots of
teeth.
107. 107
CAST SILVER SPLINTS:
Prepared from models made
from preoperative dental
impressions.
Made in two parts, one for
either side of the fracture.
Rarely used nowadays
INDICATION: Patients who are
not stable for transfer to the
operating theatre.
108. 108
GUNNING’S SPLINT
Edentulous patient
Can be wired to the jaws by
means of per alveolar,
piriform fossa or
circumzygomatic wires
109. EXTERNAL FIXATION
109
INDICATED :
patients with gross tissue
loss
when the patient is too
unwell to undergo extensive
surgery.
Place cortical screws and then
connected with an external bar
made of acrylic.
Mini-pennig orthopaedic fixator
110. INTERNAL FIXATION
110
ORIF=GOLD STANDARD
ACCESS
1.INTRAORAL INCISIONS:
gingivobuccal incisions-
Commonly used.
Resultant flap includes the
periosteum.
Sufficient cuff of mucosa is
raised so that the plate is
completely covered after
closure.
Care must be taken to
avoid inadvertent damage
to the mental nerve in the
anterior region.
112. 112
2.EXTRAORAL INCISIONS:
Indication:
#lower border of the mandible and
condylar neck,specially when there is gross
comminution or tissue loss.
Incision is made two finger breadths below the lower border of
the mandible in order to avoid damage to the mandibular branch
of the facial nerve.
Condylar neck fractures: Retromandibular incision
Higher condylar neck fractures: Preauricular incision.
113. FRACTURE PATTERNS
113
Nasal
Maxilla
LeFort I
LeFort II
LeFort III
Blowout orbit
Zygomatic
Mandibular
Frontal Sinus & Nasoethmoid
114. ANATOMY
114
Seven bones form the
bony orbit:
Maxilla, Zygoma,
Lacrimal, Ethmoid,
Palantine, Sphenoid,
Frontal
Orbital floor
=thinnest
115. 115
Blow out #: defined as
orbital floor fractures
without fracture orbital
rim, but with
entrapment one or more
soft tissue structures.
116. CLASSIFICATION
116
Pure Blow out :
BLUNT Blow from object
less than 35mm
↓
increased orbital
pressure
↓
# floor=Pure blow out
Impure blow out: fracture
line extends to orbital rim
Blow from object >35 mm
↓
# orbital rim & facial
bones
↓
increased occular pressure
↓
Impure blow out
120. Diagnosis can be confirmed by:
Forced duction test;IR entrapment
Hanging drop appearance in Water’s
view or by CT scan
When the orbital floor, being the
weakest area, gives way, herniation of
orbital contents down into the maxillary
sinus may occur (hanging drop sign).
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120
123. CT scan showing a
fracture of the left
orbital floor with
herniation of the
orbital contents_
123
124. MANAGMENT
124
Extent
Significant injury-
exploration & repair
reconstruction of the
orbital floor by
silastic sheet or bone
graft.
Otherwise balloon
support or ribbon
gauze packing of
maxillary sinus.
Endoscopic trans-antral
repair- newer method
125. 2.FRACTURE PATTERNS
125
Nasal
Maxilla
LeFort I
LeFort II
LeFort III
Blowout orbit
Zygomatic
Mandibular
Frontal Sinus & Nasoethmoid
126. 126
Fractures involving anatomical confluence of nose,
orbits and ethmoids (Complex area)
Caused by a force applied to the anterior aspect of
the face
Potentially dangerous (sharp edges can penetrate
dura resulting in leakage of CSF)
Injuries often overlooked
Reconstruction at later date extremely difficult
127. Markowitz classification
127
Type I fractures (A) single
large central fragement
segment to which the
medial canthus is attached.
Type II injuries (B) are
more comminuted than
type I but still leave a
central segment to which
the medial canthus is
attached.
Type III injuries (C), the
bone is shattered, and no
solid bone is attached to
the medial canthal tendon
128. SIGNS & SYMPTOMS
128
Loss of nasal projection
Tipping up of end of the
nose
Splaying of nasal root
Telecanthus
Blunting of canthal angle
129. MANAGEMENT
129
Type 1 #- stabilised using
miniplates
Type 2 & type 3 #- also
repaired by miniplates,
require transnasal
canthopexy to reduce
telecanthus
Injuries of lacrimal duct-
expectant management, open
laceration to be repaired
130. THE FRONTAL SINUS
130
# leads to cosmetic deformity
The principal for Rx:safe and
functional sinus and with no
cosmetic deformity
# of anterior table
Conservative- if there is no
cosmetic deformity,
Reduction and fixation-displaced
fractures .
# of posterior table
neurosurgical opinion and may
need an obliterative procedure
or cranialization with
obliteration of the frontonasal
recess and its lining
131. CSF rhinorrhoea
Cerebrospinal fluid (CSF) is a clear, colorless body
fluid found in the brain and spine,
It acts as a cushion or buffer for the brain's cortex,
132. CSF BASICS : CIRCULATION
Produced by Choroid plexus in lateral ventricle
and fourth ventricles
Through foramen of Monro
third ventricle
Through aqueduct of Sylvius
fourth ventricle
Through foramina of Luschka
Subarachnoid space over brain and spinal cord
Reabsorbed into venous sinus blood via arachnoid
granulations
133. CSF BASICS
Total volume of CSF varies from 90 to 150 m.l.
Normal CSF pressure at lumbar puncture is 50-
150 mm H2O
(It is secreted at the rate of about 20ml/h (300-
350 ml/day)
Therefore total CSF is replaced 3-5 times a day.
It rises on coughing, sneezing, nose blowing,
straining on stools or lifting heavy weight.)
135. CSF RHINORRHOEA
Defined as osseous defect of skull base with
disruption of dura and arachinoid matter leading to
Leakage of CSF into nose.
It is the failed containment of the cerebrospinal
fluid in the subarachnoid compartment
It may be clear fluid or mixed with blood.
136. Aetiology
Trauma : Most common cause. It can be either
ACCIDENTAL(80%)
SURGICAL TRAUMA(16%) includes:-
Endoscopic sinus surgery.
Trans-sphenoidal hypophysectomy
Nasal polypectomy.
Skull base surgery.
137. SPONTANEOUS LEAK: True spontaneous leaks are really rare. NUSS
postulated the various causes of spontaneous CSF rhinorrhoea. He named
them as "4 P's".
Increased intracranial pressure
Brain pulsations which continuously occur along the skull base
Extensive pneumatization of paranasal sinuses
Arachnoid pits/ villi transmission of pulsation, erodes the bone.
CONGENITAL LESIONS:
Meningocoele
Meningoencephalocoele
INFLAMMATIONS :
Mucoceles of sinuses.
Sinunasal polyposis. Erode bone and
Fungal infections of sinuses. dura.
Osteomyelitis.
NEOPLASMS: Both benign and malignant, invading the skull base.
138. SITES OF LEAKAGE
Anterior crainial fossa:
i. Cribriform plate(m c).
ii. Fovea ethmoidalis.
iii. Frontal sinus post table
Middle cranial fossa :
Injuries to sphenoid sinus
Lateral recess of sphenoid
Fracture Temporal bone:
CSF reaches middle ear and then escapes through the
eustachian tube into the nose (CSF otorinorrhoea)
139.
140. DIAGNOSIS
History of clear watery discharge from nose on
bending the head or straining.
Cannot be sniffed back
It may be seen on rising in the morning when the
patient bends his head (reservoir sign – fluid which
had collected in the sinuses, particularly sphenoid,
empties into the nose)
Nasal discharge, stiffens the handkerchief because of
its mucus content.
It should be differentiated from nasal discharge of
allergic or vasomotor rhinitis
142. Double target sign/halo sign : CSF rhinorrhoea after head
trauma is mixed with blood shows this sign when collected
on a piece of filter paper i.e. central red spot and
peripheral lighter halo.
144. Laboratory Studies
Glucose testing
Not specific
Presence of blood -> Increased glucose readings (false
positive)
Presence of meningitis or other intracranial infections
->Lower concentration of glucose in CSF (false
negative)
Glucose oxidase paper
Changes color with glucose concentrations of 5+
mg/dL
145. Beta-2-transferrin
Protein produced by enzymes only in CNS
Test requires 0.5cc of fluid
Highly sensitive 100% and specific for CSF
(Perilymph and aqueous are the only other fluids which
contain this protein, elevated in CLD, glycogen storage
disese )
If available, can get results within 3 hours
146. Beta-trace protein
Sensitivity not as high as Beta-2-transferrin
Found in CSF, heart, and serum
Elevated with renal insufficiency, multiple
sclerosis,cerebral infarctions, and some CNS tumors
Fluid with a concentration > 2.0 mg/L = Positive for
CSF
If test is available, can be accomplished in 15 minutes
147. LOCALIZATION OF SITE
High Resolution CT Scans
Bony defects
Should be 1mm cuts with axial, sagittal and coronal
views
148. 2. CT Cisternography:
It requires intrathecal injection of metrizimide/iohexol
and CT scan to localize site of leakage.
More accurate but More invasive
Sensitivity for detecting leaks drops from nearly
100% with active leaks to 60% with intermittent leaks
149. MRI
Soft tissue abnormalities (meningoencephalocoele)
pooling of CSF (high signal intensity on T2images)
More expensive
Not as good at defining bony defects
150. 3. MRI : T2 weighted image in depicting site of leak. It
requires that CSF leak is active at the time of scan.
Indicated also if encephalocele or intracranial
pathology is suspected.
151. Intrathecal injection of Fluorescein
dye
Pre/intraoperative.
Good at locating active CSF leaks
Inject a solution of 5%(0.5%-10% )Fluorescein dye (0.2 ml in
10ml CSF) through lumbar drain 1ml/min, and wait 30 minutes
with Patient in 10◦ head down position.
Dye appears green /bright yellow
Most cases - Dye can be seen without filters
Smaller defects may require filters.
Place yellow filter over endoscope and blue filter over lightsource
High doses can lead to severe side effects
Seizures
paresthesia
Tingling
Numbness
Death
153. TREATMENT
Early cases of post-traumatic CSF leak(14 days ) can be
managed by conservative measures such as bed rest,
elevation of the head of the bed,
stool softners, and avoidance of nose blowing, sneezing
and straining.
Prophylactic antibiotics can be used to prevent
meningitis.
These measures can be combined with lumbar
drainage.
154. Lumbar drain
154
High CSF pressure
Consider if CSF leak does not resolve after 5-7 days of conservative
management
Continuous drainage is recommended over intermittent drainage
Prevents spikes in CSF pressure
10-15cc/hr
Risks:
Headaches
Nausea and emesis
Pneumocephalus
Infection
155. Surgical Repair
A. Neurosurgical intracranial approach-craniotomy
success rate 50-73%
B. Extradural approaches : 76-100%
Osteoplastic flap approach for frontal sinus leak
External ethhmoidectomy for cribriform plate and
ethmoid area.
Trans-septal approach for sphenoid.
156. C. Transnasal endoscopic approach : 76-97% sucess
Most of the leaks from anterior cranial fossa and
sphenoid sinus can be managed endoscopically
ADVANTAGES
Less morbidity
Better visualisation and magnification.
Accurate positioning of the graft to plug the leak.
There is no threat of anosmia
No brain retraction
No external incision
157. 157
Principles of repair:
Defining the site of leak.
Preparation of graft site.
If an encephalocele is present cauterize stalk prior to
reduction - prevents intracranial hemorrhage.
2-5mm of bone should be exposed around the defect
Grafts - 30% larger than the defect to account for shrinkage
Grafting followed by placement of mucosa.
If bony defect>2cm, it is repaired with cartilage.
Placement of surgical and gelfoam further strengthens
area.
158. Types of graft
158
Fascia (temporalis, fascia lata)
Abdominal fat (bath plug)
Pedicled septal (HADAD flap, BAS flap) or turbinate
flaps
Cartilage, Bone (septum, middle turbinate)
Mucoperichondrium
Septal mucosa
Turbinate mucosa and/or bone
Fibrin glue -> provides improved seal
159. Selection of technique
It depends on the size and location of the defect,
< 2mm – Almost any grafting technique is
successful
2-5mm – Can typically get away with just utilizing
an overlay graft
>5mm – Composite or separate bone or
cartilage+mucosal grafts
160. Common Grafting
techniques:-
Underlay- Place graft
between dura and bony
defect
Overlay- Place graft
directly over defect
Combined-Both
underlay and overlay
grafts
Bath plug technique
161. Underlay – Btw Dura and cribriform plate
Overlay – Over the cribriform plate directly without
undermining
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161
163. BATH PLUG TECHNIQUE –
163
The technique consists
of introducing a fat plug
with a specifically
secured vicryl suture
into the intradural
space and seal the
defect placing traction
on the suture to much
as a bath plug seals a
bath.
90% sucess
164. technique
2/27/2024
164
Defining the site of
leak.-flurocein dye
Preparation of graft
site.
If an encephalocele is
present cauterize stalk
Expose 2-5mm bone
Harvest graft-prepare
Introduce intacranially
Traction-secure
Free mucosal graft
165. 165
Free mucosal graft-
threaded on the suture
Fibrin glue-seal
Surgicel /gelfoam
Check the seal
167. Pedicled nasoseptal flap (Hadad-
Bassagasteguy flap) HBF
167
Commonly used for
neurosurgical anterior
skull base /larger
defects.
WORKHORSE of ant
skull base surgery
Based on NSA-SPA
169. 169
Postoperative care
Antibiotics(prophylacticaly)
antibiotic nasal packing. For Larger defects-5 days
Lumbar drain if CSF pressure is high.
General pecautions bed rest, elevation of the head
of the bed,
stool softners, and avoidance of nose blowing,
sneezing and straining.
