The document discusses the aetiology and management of various maxillofacial traumas, focusing particularly on nasal and facial fractures stemming from incidents such as traffic accidents, sports, and assaults. It outlines the types of fractures, treatment guidelines, and complications associated with injuries to the nasal bone and facial structures. The importance of timely diagnosis and intervention, including imaging and surgical techniques, is emphasized to prevent long-term deformities and associated complications.

1. Dr. Srinivas Pennam
Maxillo-facial Trauma

2. AETIOLOGY
 Road traffic accidents
 Sports injuries
 Personal accidents
 War accidents
 Assaults & fights
 Birth injuries

3. Nasal and Facial Trauma
 Nasal trauma is extremely Common
 From birth onwards nose is assaulted
 Up to 20 % babies are found have Squished noses
 Majority spring back, but about 1-2 % are left
with a permanent deviations
 Early detection of septal abnormalities and
correction with Gray’s struts prevents idiopathic
deviated septum

5. Emergency room management
 Air way maintenance by intubation or tracheostomy
 Hemorrhage : By packing, pressure, or ligation of blood
vessels
 Tetanus
 Associated major injuries to other regions like head,
chest, spine, abdomen, neck, larynx, orbit
 Soft tissues of face
 Facial nerve
 Salivary glands

6. Bone injuries
Divisions of the facial bone injuries
 Upper third – Above the level of supra orbital
ridge
 Middle third – Between supra orbital ridge and
upper teeth
 Lower third – Mandible and lower teeth

7. Structures involved
 Nasal bones and septum
 Naso orbital region
 Zygomatic arch
 Zygoma
 Orbital floor
 Maxilla
Fractures of middle third of face

8. Fracture of Nasal Bones
 Very common injury due to prominent
projection of nose on the face
 Direct blows or falls
 As a part of facio maxillary injuries
 Often associated injuries to septum like
dislocation, fracture, buckling, haematoma
formation

9. • Type of Nasal Injury depends on
• Direction of Blow: Frontal/Lateral/ From Below
• Force of Blow
• Nasal Fractures divided into 3 Types ( Moore 1989)
• Class 1:
• Green Stick Injury
• Simple Depression of Nasal Bone
• Chevallet Fracture
• Class 2 : Jarjavay Fracture
• Class 3 : Naso- orbito -ethmoid Fracture

10. Depressed fracture
• Medium force
– Open book fracture where nasal septum collapses and nasal
bones splay out
• Greater force
– Nasal bones shattered, splaying of frontal processes of
maxilla

11. Depressed fracture

12. Angulated fracture
• Medium force  Ipsilateral nasal bone fracture
• Greater force  B/L nasal bones and septum fracture
and deviation of nasal bridge

13. Clinical features
• External nasal 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

14. Septal Fracture
 Horizontal with posterior
fracture (Jarjavay)
 Vertical with anterior
fracture (Chevallet)
 S and C shaped
deformities with healing
 Telescoping of segments
prevents closed reduction
Fracture of
Chevallet
Fracture of
Jarjavay

15. Septal Fracture

16. Nasal Fractures
 Clinical findings:
 Nasal deformity
 Edema and
tenderness
 Epistaxis
 Crepitus and
mobility

17. Clinical Features
 External deformity due to
 Fracture dislocation of
fractured bone fragments
 Odema of soft tissue
 Skin over the nasal bridge
discolored or lacerated
 Palpation over the bridge –
Tenderness or crepitus

18. Clinical Features
 Nasal obstruction – Due to Blood clots, septal
haematoma or septal deformity
 Peri orbital echymosis, sub conjunctival
haematoma
 Associated facio maxillary or head injury
 Watery nasal discharge - suspect CSF leak

19. Clinical Features
 Bony injury will be obscured by the oedema
which sets after 4 -6 hours
 Exact bony deformity can be assessed
within 2 -4 hours of trauma (or) after 6-7
days when oedema subsides

20. Diagnosis
 Clinical examination
 X-ray of the nasal bones
 X-ray P.N.sinuses

21. X- Ray nasal bones showing fracture

22. Diagnosis
 X-ray or CT scan of brain if associated head
injury suspected
 Haemoglobin to assess blood loss, Blood
group & cross matching if Hb is low.
 Opthalmological examination

23. Treatment
• Fractures without displacement : no treatment
• Fractures with displacement : closed reduction
• Open reduction required rarely for
• Infection
• Comminuted fracture
• Failed closed reduction

24. Guidelines for treatment of nasal bone
fractures
• Closed reduction done before edema appears (3hours)
or after edema subsides (7 days)
• Nasal fracture heals by 2 wk in adults and 1 wk in
children. Closed reduction is to be done before healing
• Healed deformities corrected by rhinoplasty or septo-
rhinoplasty

25. Closed reduction
1. Lift non-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

26. Closed reduction

27. Closed reduction

28. Instruments used for reduction of
fracture nasal bone

29. Left Walsham Forceps

30. Right Walsham Forceps

31. Asch Septum Forceps

32. Boies elevator
• Boies elevator 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

33. External splinting

34. Lead plate splinting for comminuted
fractures

35. Rhinoplasty for healed deformity

36. Septal Fracture reduction

37. Frontal Sinus/ Bone Fractures
Pathophysiology
 Results from a direct blow to the frontal
bone with blunt object.
 Associated with:
 Intracranial injuries
 Injuries to the orbital roof
 Dural tears

38. Frontal Sinus/ Bone Fractures
Clinical Findings
 Disruption or
crepitance orbital rim
 Subcutaneous
emphysema
 Associated with a
laceration

39. Frontal Sinus/ Bone Fractures
Diagnosis
 Radiographs:
 Facial views should
include Waters,
Caldwell and lateral
projections.
 Caldwell view best
evaluates the anterior
wall fractures.

40. Frontal Sinus/ Bone Fractures
Diagnosis
 CT Head with bone
windows:
 Frontal sinus fractures.
 Orbital rim and
nasoethmoidal
fractures.
 R/O brain injuries or
intracranial bleeds.

41. Frontal Sinus/ Bone Fractures
Treatment
 Patients with depressed skull fractures or with
posterior wall involvement.
 ENT & neurosurgery consultation.
 Admission.
 IV antibiotics.
 Patients with isolated anterior wall fractures,
nondisplaced fractures can be treated
outpatient after consultation with
neurosurgery.

42. Frontal Sinus/ Bone Fractures
Complications
 Associated with intracranial injuries:
 Orbital roof fractures.
 Dural tears.
 Mucopyocoele.
 Epidural empyema.
 CSF leaks.
 Meningitis.

43. Naso-Orbital-Ethmoidal
fracture
 Fractures that extend into
the nose through the
ethmoid bones.
 Associated with lacrimal
disruption and dural tears.
 Suspect if there is trauma
to the nose or medial orbit.
 Patients complain of pain
on eye movement.

49. Naso-Ethmoidal-Orbital
Fracture
 Clinical findings:
 Flattened nasal bridge or a saddle-shaped
deformity of the nose.
 Widening of the nasal bridge (telecanthus)
 CSF rhinorrhea or epistaxis.
 Tenderness, crepitus, and mobility of the nasal
complex.
 Intranasal palpation reveals movement of the
medial canthus.

51. Naso-Ethmoidal-Orbital
Fracture
 Imaging studies:
 Plain radiographs are insensitive.
 CT of the face with coronal cuts through the medial
orbits.
 Treatment:
 Antibiotic
 Maxillofacial consultation.

52. Orbital Blowout Fractures
 Blow out fractures are
less common.
 Occur when the the
globe sustains a direct
blunt force
 2 mechanisms of injury:
 Blunt trauma to the globe
 Direct blow to the
infraorbital rim

53. Orbital Blowout Fractures
Clinical Findings
 Periorbital tenderness,
swelling, ecchymosis.
 Enopthalmus or
sunken eyes.
 Impaired ocular
motility.
 Infraorbital anesthesia.
 Step off deformity

54. Orbital Blowout Fractures
Imaging studies
 Radiographs:
 Hanging tear drop
sign
 Air fluid levels
 Orbital emphysema

55. Orbital Blowout Fractures
Imaging studies
 CT of orbits
 Details the orbital
fracture
 Excludes retrobulbar
hemorrhage.
 CT Head
 R/o intracranial injuries

56. Orbital Blowout Fractures
Treatment
 Blow out fractures without eye injury do not
require admission
 Maxillofacial and ophthalmology consultation
 Decongestants for 3 days
 Prophylactic antibiotics
 Avoid valsalva or nose blowing
 Patients with serious eye injuries should be
admitted to ophthalmology service for further
care.

57. Transconjunctival approach

58. Transantral approach

59. Endoscopic Balloon catheter repair
 Wide MMA
 Insert Foley and
inflate
 Leave in place for
7-10 days
 Broad spectrum
antibiotics

60. Fracture of middle third of the face
It is the fracture of facial bones, supra orbital ridge and upper
teeth
Types :
Depending on the site
 Central (Naso
maxillary bones)
 Lateral (Malar
maxillary bones)

61. Maxillary Fractures
 High energy injuries.
 Impact 100 times the force of gravity is
required .
 Patients often have significant multisystem
trauma.
 Classified as LeFort fractures.

62. Types
Le Fort 1 = Transverse
Le Fort 2 = Pyramidal
Le Fort 3 = Cranio -facial
dysjunction

63. Le Fort 1 (Guerin) fracture
Runs above nasal floor, through nasal septum,
maxillary sinuses & inferior parts of pterygoid plates

64. Le Fort 2 fracture
Runs obliquely from maxillary sinus floor to infraorbital
margin, across orbital floor & lacrimal bone to nasion

65. Le Fort 3 fracture
Runs from medial orbit wall to superior orbital fissure
across sphenoid & zygomatic bone to zygomatico -
frontal suture inferiorly to pterygoid plates

66. Clinical Features
 Nose
 Collapse of nasal bridge
 Oedema of soft tissues
 Epistaxis
 Septal haemotoma
 Nasal obstruction
 C.S.F Rhinorrhoea

67. Maxillary sinus
 Step deformity of infraorbital margin due
to fracture
 Oedema of soft tissues
 Infra orbital involvement – Anaesthesia or
numbness over cheek

68. Face
 Flattening of face – Dish
faced deformity
 Mal occlusion of jaws
Eyes
 Epiphora
 Sub conjunctival
haemorrhage
 Diplopia
 Enophthalmos

69. Fracture reduction
• Closed methods
• Hard palate disimpaction with Rowe’s forceps
• External fixation on halo frame, box frame
• Inter-maxillary fixation
• Open methods
• Inter-osseous wiring
• Compression plates & screws

70. Hard palate disimpaction

71. External fixation

72. Inter-maxillary fixation

73. Inter-osseous wiring

74. Compression plates

75. Lateral Type - Zygoma Fractures
Malar maxillary complex fracture due to blow
from the side of the face
 Two types of fractures can occur:
 Arch fracture (most common)
 Tripod fracture (most serious)

76. Zygoma Arch Fractures
 Can fracture 2 to 3 places along the arch
 Lateral to each end of the arch
 Fracture in the middle of the arch
 Patients usually present with pain on opening their
mouth.

77. Zygoma Arch Fractures
Clinical Findings
 Palpable bony defect
over the arch
 Depressed cheek with
tenderness
 Pain in cheek and jaw
movement
 Limited mandibular
movement

78. Zygoma Arch Fractures
Imaging Studies & Treatment
 Radiographic imaging:
 Submental view
(bucket handle view)
 Treatment:
 Consult maxillofacial
surgeon
 Ice and analgesia
 Possible open elevation

79. Zygoma Tripod Fractures
 Tripod fractures
consist of fractures
through:
 Zygomatic arch
 Zygomaticofrontal
suture
 Inferior orbital rim and
floor

80. Clinical features:
 Periorbital edema and ecchymosis
 Hypesthesia of the infraorbital nerve
 Concomitant globe injuries are common
 Flattening of malar prominence
 External swelling
 Step deformity of infra orbital ridge
 Enopthalmos
 Trismus
 Diplopia

81. Zygoma Tripod Fractures
Imaging Studies
 Radiographic imaging:
 Waters, Submental and
Caldwell views
 Coronal CT of the
facial bones:
 3-D reconstruction

82. Zygoma Tripod Fractures
Treatment
 Nondisplaced fractures without eye involvement
 Ice and analgesics
 Delayed operative consideration 5-7 days
 Decongestants
 Broad spectrum antibiotics
 Displaced tripod fractures usually require
admission for open reduction and internal
fixation.

83. Investigations
 Radiography
 CT – If necessary in cases of CSF rhinorrohoea

84. Treatment
 Reduction of fractures, under GA
 Reduced fragments are maintained in place
by use of steel wires,splints, rods and
traction

85. Gillies Reduction

86.  Reduction
1.Gillies temporal approach -
 Infiltration with local anaesthetic and
adrenaline
 Small incision is made down to superficial
temporal fascia
 Fascia is incised and elevator is passed down
on temporalis muscle so that its tip lies just
under the fracture.
 The bone is then elevated.

88. 2.poswillo hook
 Hook is inserted at intersection of a
line drawn vertically from lateral
orbital margin and a horizontal line
drawn from inferior margin of nose.
 Stab incision is given and hook is
inserted
 Zygoma is lifted back into position

89. 3.Intra oral or keen approach-
 Mucogingival incision is given in buccal sulcus in molar
/premolar region
 An elevator is passed behind zygomatic body to elevate
fracture.
 Open reduction-
 Zygoma may be plated at frontozygomatic suture, infra
orbital margin, zygomatic buttress ,zygomatic arch
 Periosteum should be closed meticulously over the plate

90. Post operative care
 Patient instructed not to blow nose for first 12 hours.
 Watch out for signs of retrobulbar hemorrhage(increasing
pain,proptosis,ophthalmoplegia,diminishing visual acuity)
 Treatment-
 Dexamethasone 4 mg/kg bolus,2 mg/kg 6 hrly
 Acetazolamide 500 mg IV
 Mannitol 20% 200 ml
 Remove the sutures and do surgical decompression by lateral canthotomy

91. C.S.F Rhinorrhoea

92. C.S.F Rhinorrhoea
It is the flow of cerebrospinal fluid from the nose
Sites of CSF Leak
 Cribriform plate of Ethmoid
 Frontal sinus
 Ethmoidal sinus
 Sphenoid sinus

93. C.S.F Rhinorrhoea
Aetiology
 Congenital – Congenital Dehiscence of
Nasal roof
 Traumatic
 Head Injury – Fracture of floor of anterior
cranial fossa

94. Iatrogenic
 Functional endoscopic sinus surgery (FESS)
 Ethmoidectomy, sphenoidectomy
 Trans nasal hypophysectomy
 Frontoethmoidal mucocele surgery
 SMR / Septoplasty

95. C.S.F Rhinorrhoea
 Spontaneous
 Raised intracranial tension
 Hydrocephalus
 Destructive bony lesions like granulomas
 Tumors

97. Clinical Features
 Rhinorrhoea – Unilateral, clear, watery, dripping
on looking downwards, increase on coughing,
sneezing, and on exertion
 History of Trauma - Accidental or operation on
nose or PNS
 Head Ache
 Meningitis – Rarely the presenting feature

98. Diagnosis
 To be differentiated from nasal discharge
 History
 Collection of fluid in test tube, allowed to stand
 CSF – Remains clear
 Nasal discharge – forms sediment
 Handkerchief test for nasal discharge – Handkerchief
stiffens

99. Double ring sign or halo sign
 Traumatic cases
 Discharge collected on a
tissue paper
 Central spot of blood, CSF
spreads as halo around it
 DIAGNOSTIC
NASAL
ENDOSCOPY

100. Diagnosis
 Fluorescein dye test
 Endonasal endoscopic evaluation following
lumbar intrathecal administration of sodium
fluorescein.
 Using flurescein blue light filter system coupled
to cold light source the site of leak is assessed
accurately
 Β2 TRANSFERIN PRESENT IN CSF

101. RADIOLOGICAL
 X-Ray skull bones
 CT Scan or CT Cisternography
 MRI or MRI Cisternography

103. TREATMENT
 Complete bed rest with raised head end
 Avoid blowing nose, sneezing or straining
 Avoid nasal packs or nasal drops
 Antibiotics
 Mannitol and acetazolamide to reduce intracranial
pressure
 Treat the cause

104. SURGICAL REPAIR
 External ethmoidectomy approach
(Rarely done now a days)
 Nasal endoscopic approach
 Intracranial of approach

105. Marquis Alfonso Corti worked on the mammalian auditory system at
the Koelliker Laboratory in Wurzburg (Germany). In 1851, he
published a paper describing a structure located on the basilar
membrane of the cochlea containing hair cells that convert sound
vibrations into nerve impulses: the organ of Corti

106. Knowledge is power