Intern’s Hour

Maxillofacial TraumaPreceptor: Dr. Germar

BLOCK R

The Case

24-year-old male who sustained traumatic injuries during a soccer game

DOI: 3/18/2010 TOI: 7 AM POI: soccer field MOI: Few hours PTC, the patient,

a soccer goalkeeper, attempted to recover a loose ball when he was struck in the face by an opponent’s knee.After contact, the patient fell to the ground on his left side in a side-lying position.

Review of Systems

(-) LOC (-) seizure (+) headache (+) dizziness (-) vomiting (-) rhinorrhea/

epistaxis (-) otorrhea

(-) dyspnea (-) chest pain (-) abdominal pain (-) urinary and

bowel changes

Physical Examination

VS: BP 130/80, HR 86, RR 20, afeb

HEAD and NECK: (+) R periorbital edema

with subconjunctival hemorrhage, OD

R facial swelling and tenderness

(+) crepitus on R maxillary area

(+) upper lip laceration (-) malocclusion, able to

open mouth to 4 fingerbreaths

Physical Examination

HEART AP, DHS, NRRR, apex beat @ 5th ICS

LMCL, (-) murmurCHEST and LUNGS

ECE, CBS, (-) crackles/ wheezesABDOMEN

Soft, flat abdomen, NABS, (-) tendernessEXTREMITIES

PNB, FEP, (-) cyanosi/ edema

Physical Examination

NEURO GCS 15 (E4V5M6), oriented to 3 spheres CN intact Motor strength 5/5 on all extremities (-) sensory deficit DTRs 2+, (-) Babinski Supple neck

Assessment

Multiple Injuries 2⁰ to --- 1. R periorbital contusion with

subconjunctival hemorrhage of the R eye 2. t/c R maxillary fracture r/o intracranial injury

Course

Upon arrival at the ER, A: with the athlete in the supine position, an

attempt to open the airway using a modified jaw-thrust maneuver was performed.

B: the breathing can be compromised as a result of blood from ongoing facial bleeding. After blood was quickly cleared from the face, the source of bleeding was identified in the upper lip, which had sustained a complete through-and-through laceration. Direct pressure was immediately applied.

C: blood pressure was noted to be normal, cervical spine was secured

Diagnostics

CBC Blood type PT/PTTNa, K, Cl, BUN, Crea

Diagnostics

Towne’s, Water’s, SMV radiographs of the chest, cervical

spine The radiographs revealed no evidence of

vertebral fracture or pulmonary diseasecomputed tomography (CT) scans of

the brain and face

CT scan

The CT scans identified fractures of the anterior, posterior, and medial walls of the right maxillary sinus. A small pocket of air was identified in the right infratemporal fossa, suggesting an occult fracture of the lateral wall of the right maxillary sinus. The initial facial CT scan also suggested a fracture of the floor of the right orbit.

The cranial CT showed no evidence of skull fracture or intracranial injury.

Final Diagnosis

Multiple Injuries 2⁰ to --- 1. R periorbital contusion with

subconjunctival hemorrhage of the R eye 2. R maxillary fracture

1. Fractures of the Nasal Pyramid

2. Fractures of the Central Midface

Le Fort Fractures

3. Fractures of the Lateral Midface

4. Fractures of the Frontal bone

5. Fractures of the Anterior Skull Base

Escher Classification

6. Fractures or dislocation of the mandible

Sports Vehicular Accidents Mauling

Women – consider the possibility of domestic violence

Patients with severe facial trauma: multisystem trauma potential for airway compromise concurrent brain injury cervical spine injuries blindness

Primary Survey Airway Breathing Circulation

Secondary Survey

Airway: Chin lift. Jaw thrust. Oropharyngeal suctioning Manually move the tongue forward

Maintain cervical immobilization

Avoid nasotracheal intubation Adverse effects:▪ Nasocranial intubation▪ Nasal hemorrhage

cricothyroidotomy

Circulation:

Direct pressure

Anterior and posterior nasal packing

Packing of the pharynx around ET tube

Place, Time, Date, Mechanism of injury

Detailed description of the circumstances surrounding the injury

Allergies, other medical problems, medications, tetanus immunizations

Questions: Was there LOC, nausea/vomiting, headache? (Head

Trauma related questions) How is your vision? Hearing problems? Is there pain with eye movement? Are there areas of numbness or tingling on your

face? Able to bite down without any pain? Is there pain with moving the jaw?

Inspection Open wounds for foreign

bodies

Facial asymmetry

Nose for deviation, widening of bridge

Nasal septum for septal hematoma, CSF or blood

Ears for blood or CSF

Malocclusion

Raccoon eyes

Inspection

Battle’s sign

Inspection

Otorrhea, Rhinorrhea

Halo Sign

Not sensitive or specific but can be used as a preliminary test for CSF in blood

Dipstick

Beta transferrin

Palpation Palpate the entire face.

Supraorbital and Infraorbital rim Zygomatic-frontal suture Zygomatic arches

Nose - crepitus, deformity and subcutaneous air Zygoma along its arch and its articulations with

the maxilla, frontal and temporal bone Mandible for tenderness, swelling

Intraoral examination: Inspect the teeth for malocclusions, bleeding

Manipulation of each tooth

Check for lacerations

Mandibular movements

Ophthalmologic exam

Visual acuity Pupils for shape and

reactivity Eyelids for lacerations Extra ocular muscles Palpate around the

orbits

Examine and palpate the exterior ears

Otoscopic examination Look for lacerations TM rupture

Plain films Confirm suspected clinical diagnosis Determine extent of injury Document fractures

CT scan

ATS, TeAna Thorough evaluation of all wounds All foreign bodies must be removed Debridement Suturing of lacerations as needed Minimize scarring Antibiotics

Most common bone injury in the face

Open or closed

Signs Depression or

displacement of nasal bones

Edema of nose Epistaxis Fracture of septal

cartilage with displacement or mobility

Crepitus on palpation

All nasal injuries should be evaluated for septal hematoma

Untreated- result in septal necrosis and saddle nose deformity

Can become infected- result in a septal abscess

Radiographs: Lateral projection

Treatment: Surgical

After reduction, nasal cavities should be packed – “internal splinting”

Le Fort’s classification Le Fort I (transverse maxillary) Le Fort II (pyramidal) Le Fort III (craniofacial dysjunction)

Low transverse fracture of maxilla involving palate

Facial edema Mobility of hard

palate and upper teeth

Malocclusion

Pyramidal fracture with detachment of maxilla

Facial edema Epistaxis Bilateral

periorbital edema and ecchymosis

Complete disruption of attachments of facial skeleton to cranium

Movement of all facial bones in relation to the cranial base with manipulation of the teeth and hard palate

Open patient’s mouth and grasp the maxilla arch Place the other hand on the forehead Gently move back and forth, up and down - check for movement of maxilla

Massive edema with facial elongation, flattening – “Dish faced deformity”

Epistaxis and CSF rhinorrhea

Motion of the maxilla, nasal bones and zygoma

Open reduction and intermaxillary fixation should be performed to establish correct occlusion

Followed by rigid fixation at the piriform rims and zygomaticomaxillary buttress.

The zygoma has 2 major components: Zygomatic arch Zygomatic body

Two types of fractures can occur: Isolated Arch fracture -most common Tripod fracture - most serious

Palpable bony defect over the arch

Flattening of the cheek

Pain in cheek and jaw movement

Limited mandibular movement

Radiographic imaging: Submental view

“bucket handle view”

- Arches may not be seen in usual views (anterior, lateral)

Treatment: Symptomatic -

surgical

Tripod fractures consist of fractures through: Zygomatic arch Zygomaticofrontal

suture Inferior orbital rim

and floor Symptoms

Periorbital edema Sensory

disturbances along the infraorbital nerve

WatersCaldwellSubmental Coronal CT

Treatment: Symptomatic -

surgical

Isolated fracture of the orbital floor with partial herniation of orbital contents

Facial asymmetry

Enophthalmos

Diplopia on upward gaze- impingement of inf. Rectus

Check for sensory disturbances – cheek, upper lip, lateral nasal wall

CT scan

Management: Indicated for displaced fractures or for

symptomatic fractures

Uncommon Depression of

anterior table of frontal sinus

Intracranial injuries Dural tears EpistaxisCSF rhinorrhea (disruption of

posterior table of frontal sinus with dural rupture)

Radiographs: Facial views should

include: ▪ Waters ▪ Caldwell ▪ lateral projections

Caldwell view best evaluates the anterior wall fractures

Cranial CT with bone window Frontal sinus

fractures. Orbital rim and

nasoethmoidal fractures

R/O brain injuries or intracranial bleeds

Patients with depressed skull fractures or with posterior wall involvement. ENT or nuerosurgery consultation. Admission. IV antibiotics. Tetanus.

Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.

Associated with intracranial injuries Orbital roof fractures Dural tears Mucopyocoele Epidural empyema CSF leaks Meningitis

2nd most commonly fractured facial bone

Signs and symptoms Malocclusion of teeth Tooth mobility Intraoral lacerations Pain on mastication Bone deformity

Mandibular pain

Malocclusion of the teeth

Separation of teeth with intraoral bleeding

Inability to fully open mouth

Preauricular pain with biting

Positive tongue blade test

Radiographs: Panorex Plain view: PA, Lateral and a Townes view

Treatment: Nondisplaced fractures:

Analgesics Soft diet Dent/ORL surgery referral

Displaced fractures, open fractures and fractures with associated dental trauma Urgent oral surgery consultation

All fractures should be treated with antibiotics and tetanus prophylaxis.

PLAN

AntibioticsPain managementSuture the upper lip laceration.The facial fractures are nondisplaced

and do not require surgery. These facial fractures should be followed for evidence of healing.

THANK YOU!