TRAUMA MAXILOFACIAL

MAXILOFACIAL TRAUMAPresenter: - Wisnu Adiputra (07120080072)- Nofilia Citra Candra (07120090066)BHAYANGKARA TK. I RADEN SAID SUKANTO HOSPITALFACULTY OF MEDICINE PELITA HARAPAN UNIVERSITYJAKARTA

Definition of TraumaA term derived from the Greek for WOUNDIt refers to any bodily injury.It defined as tissue injury due to direct effects of externally applied energy. Energy may be mechanical, thermal, electrical, electromagnatic or nuclear.Included:burns, drowning, smoke, inhalation, slip & fall.Excluded: poisoning/toxic ingestion.

Initial Assessment

SurveySafe?What happen?Count the victimHow many helper?Help

SURVEYTRIAGEBlack or white: DeadRed:patient with heavy trauma, combusio with high BSAYellow : extremity fracture without heavy hypovolemic shockGreen: minimal trauma

PRIMARY SURVEYA : Airway with cervical spine protect.B : BreathingC : Circulation --control external bleeding.D : Disability or neurological statusE : Exposure (undress) & Environment (temp control)

Glasgow coma scale (GCS)(Teasdale and Jennett, 1974)Eye openingMotor responseVerbal responseSpontaneous4Move to command6Converse5To speech3Localizes to pain5Confused4To pain2Withdraw from pain4Gibberish3none1flexes3grunts2Extends2none1none18Score 8 or less indicates poor prognosis, moderate head injury between 9-12 and mild refereed to 13-15AirwayLOOK

LISTEN

FEEL

AirwayIs there any obstruction?Protection of the spine & spinal cord is the important management principle.Do chin lift or jaw thrustGCS < 8 consider of definitive airway

Can talk = airway clear

1/0011Indication For Definite Airway* Unconscious* Severe maxillo-facial fracture* Risk for aspiration : Bleeding/ vomiting* Risk for obstruction : neck hematoma/laryngeal,tracheal injury/ stridor* Apnea : Neuromuscular paralysis/unconscious* Inadequate respiratory effort: tachypnea/hypoxia/hypercapnia/cyanosis* Severe closed head injury need for hyperventilation

BREATHINGBreathing dan VentilasiChest expansionAuskultasi (if possible)Percussion : hyporesonance(fluid) dan Hyperesonance(air)

8 lethal Injury1. Simple pneumothorax2. Hemothorax3. Pulmonary contusion4. Tracheo-bronchial tree injury5. Blunt cardiac injury6. Traumatic aortic disruption7. Traumatic diaphragmatic injury8. Mediastinal traversing wounds.

Breathing InterventionsVentilate with 100% oxygenNeedle decompression if tension pneumothorax suspectedChest tubes for pneumothorax / hemothoraxOcclusive dressing to sucking chest woundIf intubated, evaluate ETT position

CIRCULATIONCirculationHemorrhagic shock should be assumed in any hypotensive trauma patient

1. Blood Volume & Cardiac Output a. level of consciousness. b. skin color and capillary refill c. Pulse.: Normal ( 60-100x/min) Tachycardi ( >100x/min Bradycardi ( 40% loss

Circulation InterventionsCardiac monitorApply pressure to sites of external hemorrhageEstablish IV access2 large bore IVsCentral lines if indicatedCardiac tamponade decompression if indicatedVolume resuscitationHave blood ready if neededLevel One infusers available Foley catheter to monitor resuscitation19Contraindications of foley catheter (signs of possible urethral injury): 1. Blood at urethral meatus 2. Perineal eccymosis 3. Blood in the scrotum 4. High riding prostate 5. Pelvic FracturesIf suspicious of urethral injury---retrograde urethrogram prior to insertion1/00203 for 1 Rule

a rough guideline for the total amount of crystalloid volume acutely is to replace each ML of blood loss with 3 ML of crystalloid fluid, thus allowing for restitution of plasma volume lost into the interstitial & intracellular space

201/0021Initial Fluid Therapy

Lactated Ringer is preferred * For adult 1-2 liters bolus * For child 20ml/kg bolus

DisabilityDisability ( Neurological Evaluation)Simple Mnemonic to describe level of consciousnessA : AlertV : Responds to Vocal stimuliP : Responds to Painful stimuliU : Unresponsive to all stimuli

Not forget to use also Glascow Coma Scale.

Disability InterventionsSpinal cord injuryHigh dose steroids if within 8 hoursICP monitor- Neurosurgical consultationElevated ICPHead of bed elevatedMannitolHyperventilationEmergent decompressionEXPOSUREExposure / Environmental Control-It is the pts body temp that is most important, not he comfort of the health care provider.-Intravenous fluid should be warm. -Warm environment (room tem) should be maintained.-early control of hemorrhage.-Complete disrobing of patient-Logroll to inspect back

E- ExposureComplete disrobing of patientLogroll to inspect backRectal temperatureWarm blankets/external warming device to prevent hypothermiaAlways Inspect the Back

RESUSCITATIONA. Airway*definite airway if there is any doubt about the pts ability to maintain airway integrity.B. Breathing /Ventilation/Oxygenation*every injured pt should received supplement oxygenC. Circulation*control bleeding by direct pressure or operative intervention* minimum of two large caliber IV should be established*pregnancy test for all female of child bearing age.* Lactated Ringer is preferred & better if warm. 3 for 1 rule

Secondary survey

Although maxillofacial injuries is part of the secondary survey, OMFS might be involved at early stage if the airway is compromised by direct facial traumaHead InjuryFacial injuryChest InjuryAbdominal injuryInjury to extremities29Facial Trauma SECONDARY SURVEYHistory: Three key questionsVision changes?Monocular double vision Lens disruption, or corneal or retinal injuryBinocular double vision Dysfunction of extraocular muscles or nervesPain w/ movement = injury to orbit or globeFacial numbness Trigeminal branch nerve injuryMalocclusion Fracture or dislocation30Facial Trauma - EvaluationPhysical ExamInspectionFacial elongation (Donkey Face) associated with high grade Le Forte fracturesFacial asymmetry - neural involvementEcchymosis - Raccoons eyes or Battles signPalpationAssess for tenderness, crepitus or subcutaneous airIntraoral exam for zygomatic arch injury and maxillary stability31Facial Trauma - EvaluationPhysical ExamOrbital examination Done early before swellingPupil reactivityTear drop pupil associated with globe ruptureMarcus Gunn pupilHyphemaVisual acuityEOMOcular muscle entrapmentOcular nerve injuryPain can be a clue to associated orbit fracturesProptosis - consider retrobulbar hematoma32Marcus Gunn pupil = afferent defect, damage to optic nerve or retinaFacial Trauma - EvaluationPhysical Exam - Orbital ExaminationLid LacerationsMedial third of lower eyelidHigh risk for lacrimal duct involvementUpper and Lower EyelidDisruption of tarsal plate or cartilaginous plateEyelid DroopDisruption of levator palpebral muscle

Grays Anatomy (Wikipedia)

Grays Anatomy (Wikipedia)33Injuries to tarsal plate and levator palpebral muscle require special cosmetic considerationsFacial Trauma - EvaluationPhysical ExamNoseSeptal hematomaRequires immediate evacuation to prevent pressure necrosis of the nasal septumCSF Rhinorrhea Indicates cribriform plate disruptionDeformityIndicates nasal bone fractureEarsCSF leakHemotympanumBattles sign - indicates basilar skull fracture34Facial Trauma - EvaluationPhysical ExamMandible/DentitionMalocclusionFlail mandible - two separate fracture siteTMJ dislocation - typically anteriorTongue blade testPatient bites down on tongue blade and it is twisted until it breaks: Unable to break tongue blade indicates mandibular fracture95% sensitive; 65% specific for mandibular fractureLoose/chipped teeth35Secondary SurveyNeurologicSkin fold symmetry at restMotor: each division of CN-VIISensation: 3 divisions of CN-VSensation on tongueGag reflexFacial Trauma - ImagingPlain filmsChallenging to readApproachAsymmetryBony integritySubcutaneous airSinus opacityTeardrop sign - orbital fat herniation37Facial Trauma - ImagingPlain filmsWaters or occipital-mental viewAs sensitive a entire facial seriesExamines orbital rims and air/fluid levelsPA or Caldwell viewBest for upper facial bonesSubmental-vertex (jug handle) viewBest to evaluate for zygomatic arch fracturesTowne viewEvaluation of mandibular ramus38

Jug HandleWaters

Facial Trauma - ImagingCTConsidered by some to be one of the two most important advancements in the last 20 years.Helps guide surgical management

RadiologyInfo.org

41The other big advancement being the use of small plates and screws instead of wire fixation for repairHead injury

Many of facial injury patients sustain head injury in particular the mid face injuries

Open

Closed

it is ranged from Mild concussion to brain death42Signs and symptoms of head injuryLoss of conscious ORHistory of loss of consciousHistory of vomitingChange in pulse rate, blood pressure and pupil reaction to light in association with increased intracranial pressure

Assessment of head injury (behavioral responses motor and verbal responses and eye opening)

Skull fractureSkull base fracture (battles sign)Temporal/ frontal bone fractureNaso-orbital ethmoidal fracture

43Cervical spine injury Can be deadly if it involved the odontoid process of the axis bone of the axis vertebra

If the injury above the clavicle bone, clavicle collar should minimize the risk of any deteriorationPt with maxillofacial or head trauma should be presumed to have and unstable cervical spine.

44

Breathing and ventilationChest injuries: Pneumothorax, haemopneumothorax, flail segments, reputure daiphram, cardiac tamponadesigns45Clinical Deviated tracheaAbsence of breath soundsDullness to percussionParadoxical movementsHyper-response with a large pneumothoraxMuffled heart soundsRadiographicalLoss of lung markingDeviation of tracheaRaised hemi-diaphragmFluid levelsFracture of ribsEmergency treatment in case of chest injuryOccluding of open chest wounds

Endotreacheal intubation for unstable flail chest

Intermittent positive pressure ventilation

Needle decompression of the pericardium

Decompression of gastric dilation and aspiration of stomach content46Hemorrhage Acute bleeding may lead to hemorrhagic shock and circulatory collapse

Abdominal and pelvis injury; liver and internal organs injury (peritonism)

Fracture of the extremities (femur)47Abdomen and pelvis In addition to direct injuries, loss of circulating blood into peritoneal cavity or retroperitonial space is life threatening, indicated by physical signs and palpation, percussion and auscultation

Management:Diagnostic peritoneal lavage (DPL) to detect blood, bowel content, urineEmergency laparotomy48Abdominal TraumaLook for distension, tenderness, seatbelt marks, penetrating trauma, retroperitoneal ecchymosisBe suspicious of free fluid without evidence of solid organ injury

Extremity trauma

Fracture of extremities in particular the femur can be a significant cause of occult blood loss. Straightening and reduction of gross deformity is part of circulation control

Cardinal features of extremities injuryImpaired distal perfusion (risk of ischemia)Compartment syndrome (limb loss)Traumatic amputation 50Patient hospitalization and determination of priorities

Facial bone fracture is hardly ever an urgent procedure,simple and minor injury of ambulant patient may occasionally mask a serious injury that eventually ended the patients life emergency cases require instant admission conditions that may progress to emergency cases with no urgency 51Preliminary treatment in complex facial injurySoft tissue laceration (8 hours of injury with no delay beyond 24 hours)

Support of the bone fragments

Injury to the eye As a result of trauma, 1.6 million are blind, 2.3 million are suffering serious bilateral visual impairment and 19 million with unilateral loss of sight (Macewen 1999)Ocular damageReduction in visual acuityEyelid injury52Prevention of infectionFractures of jaw involving teeth bearing areas are compound in nature and midface fracture may go high, leading to CSF leaks (rhinorrhoea, otorrhoea) and risk of meningitis,and in case of perforation of cartilaginous auditory canal

Diagnosis: Laboratory investigation, CT and MRI scanManagement:Dressing of external woundsClosure of open woundsReposition and immobilization of the fracturesRepair of the dura matterAntibacterial prophylaxis (as part of the general management (Eljamal, 1993)

53Control of pain Displaced fracture may cause severe pain but strong analgesic ( Morphine and its derivatives) must be avoided as they depress cough reflex, constrict pupils as they may mask the signs of increasing intracranial pressure

Management:

Non-steroidal anti-inflammatory drugs can be prescribed (Diclofenac acid)

Reduction of fracture

sedation54SECONDARY SURVEYDoes not begin until the primary survey (ABCDEs) is completed, resuscitative effort are well established & the pt is demonstrating normalization of vital sign.

SECONDARY SURVEYHistory A : Allergies.M: Medication currently used. P : Past illness/ Pregnancy. L : Last Meal E: Events/Environment related to the injury. *blunt trauma/penetrating trauma/injuries due to cold & burn/hazardous environment?

Fracture ClassificationMajorLefort I, II, IIIMandibularMinorNasalSinus wallZygomaticSupraorbital Orbital floor

Lefort FracturesLefort fractures can coexist with additional facial fracturesPatient may have different Lefort type fracture on each side of the faceDifferentiating LefortsPull forward on maxillary teethLefort I: maxilla only movesLefort II: maxilla & base of nose move:Lefort III: whole face moves:

Lefort I: NasomaxillaryHorizontal fracture extending through maxilla between maxillary sinus floor & orbital floorCrepitus over maxillaEcchymosis in buccal vestibuleEpistaxis: can be bilateralMalocclusionMaxilla mobilityLefort I: NasomaxillaryClosed reductionIntermaxillary fixation: secures maxilla to mandibleMay need wiring or plating of maxillary wall and / or zygomatic archAntibiotics: anti-staphylococcalLefort II: PyramidalSubzygomatic midfacial fracture with a pyramid-shaped fragment separated from cranium and lateral aspects of faceLefort II: PyramidalSigns & symptomsMidface crepitusFace lengtheningMalocclusionBilateral epistaxisInfraorbital paresthesiaEcchymoses: buccal vestibule, periorbital, subconjunctival Lefort II: PyramidalHemorrhage or airway obstruction may require emergent surgeryTreatment can often be delayed till edema decreasedLefort II: PyramidalUsually requireIntermaxillary fixationInterosseous wiring or plating of infraorbital rims, nasal-frontal area, & lateral maxillary wallsMay need additional suspension wiresAntibiotics Lefort IIICraniofacial dissociationBilateral suprazygomatic fracture resulting in a floating fragment of mid-facial bones, which are totally separated from the cranial baseLefort IIISigns and SymptomsFace lengthening: caved-in or donkey faceMalocclusion: open biteLateral orbital rim defectEcchymoses: periorbital, subconjunctivalLefort IIISigns and SymptomsBilateral epistaxisInfraorbital paresthesiaOften medial canthal deformityOften unequal pupil heightLefort IIIUsually associated with major soft tissue injury requiring emergent surgery for bleeding controlSurgery can be delayed till edema resolvesIntermaxillary fixationLefort IIITransosseous wiring or platingFrontozygomatic sutureNasofrontal sutureMay need extracranial fixation if concurrent mandibular fractureAntibiotics Mandible FracturesAirway obstruction from loss of attachment at base of tongue>50 % are multipleCondylar fractures associated with ear canal lacerations & high cervical fracturesHigh infection potential if any violation of oral mucosa

Mandible FracturesSigns and symptomsMalocclusionDecreased jaw range of motionTrismusChin numbnessEcchymosis in floor of mouthPalpable step deformityMandible FracturesTongue blade test: have patient bite down while you twist. If no fracture, you will be able to break the blade.

TMJ DislocationCan occur from direct blow to mandibleCan occur spontaneously from yawning or laughingMandible dislocates forward & superiorlyConcurrent masseter & pterygoid spasm

TMJ DislocationSymptomsPatient presents with mouth open, cannot close mouth or talk wellCan be misdiagnosed as psychiatric or dystonic reactionTMJ DislocationTreatmentManual reduction: place wrapped thumbs on molars & push downward, then backwardBe careful not to get bittenUsually does not require procedural sedation or muscle relaxantsNasal Bone FracturesOften diagnosed clinically: x-ray not neededEmergent reduction not necessary except to control epistaxisUsually do not need antibioticsEarly reduction under local anesthesia useful if nares obstructedNasal Bone FracturesNasal septal hematoma: incise & drain, anterior pack, antibiotics, follow-up at 24 hoursFollow-up timing for recheck or reduction:Children: 3 to 5 daysAdults: 7 daysZygomatic FracturesTripod (tri-malar) fractureDepression of malar eminenceFractures at temporal, frontal, and maxillary suture linesZygomatic FracturesIsolated arch fractureLess commonShows best on submental-vertex x-ray viewPainful mandible movementUsually treat with fixation wire if arch depressedZygomatic FracturesTripod S & SUnilateral epistaxisDepressed malar prominenceSubcutaneous emphysemaOrbital rim step-offAltered relative pupil positionPeriorbital ecchymosisSubconjunctival hemorrhageInfraorbital hypoesthesiaSupraorbital FracturesFrontal sinus fractureOften associated with intracranial injuryOften show depressed glabellar areaIf posterior wall fracture, then dura is tornSupraorbital FracturesEthmoid fractureBlow to bridge of noseOften associated with cribiform plate fracture, CSF leakMedial canthus ligament injury needs transnasal wiring repair to prevent telecanthusOrbital FracturesBlow out fracture of floorRule out globe injuryVisual acuityVisual fieldsExtraocular movementAnterior chamberFundusFluorescein & slit lamp

Orbital FracturesSymptoms and signsDiplopia: double visionEnophthalmos: sunken eyeballImpaired EOMsInfraorbital hypesthesiaMaxillary sinus opacificationHanging drop in maxillary sinusOrbital FracturesDiplopia with upward gaze: 90%Suggests inferior blowoutEntrapment of inferior rectus & inferior obliqueDiplopia with lateral gaze: 10%Suggests medial fractureRestriction of medial rectus muscleOrbital Fracture: TreatmentSometimes extraocular muscle dysfunction can be due to edema and will correct without surgeryPersistent or high grade muscle entrapment requires surgical repair of orbital floor (bone grafts, Teflon, plating, etc.)

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Top To BottomFacial Soft Tissue InjuriesBefore repair, rule out injury to:Facial nerveTrigeminal nerveParotid ductLacrimal ductMedial canthal ligamentRemove embedded foreign material Facial Soft Tissue RulesFor lip lacerations, place first suture at vermillion borderNever shave an eyebrow: may not grow backIf debridement of eyebrow laceration needed, debride parallel to angle of hairs rather than verticallyFacial Soft Tissue RulesAntibiotics for 3 to 5 days for any intraoral laceration (penicillin VK or erythromycin) and if any exposed ear cartilage (anti-staphylococcal antibiotic) no evidenceRemove sutures in 3 to 5 days to prevent cross-marksFacial Soft Tissue RulesMost face bite wounds can be sutured primarilyClean facial wounds can be repaired up to 24 hours after injuryPlace incisions or debridement lines parallel to the lines of least skin tension (Lines of Langer)SUMMARYAssess ABC's firstDo complete exam as part of secondary surveyObtain standard X-rays and / or CT scan as indicatedDecide if specialist referral and / or operative repair indicatedArrange followup after repair to assess for delayed complications or cosmetic problems

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