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EMERGENCY IN MAXILLOFACIAL INJURIESDr K.C.Mallik., M.S

SYNONYMS:-Facial trauma, facial fractures, upper and lower jaw fractures or brokenjaws

Fig No.:-1-Leforte III fracture Fig No.:-2-Maxillofacial trauma

INTRODUCTION

Maxillofacial trauma or injuries are commonly encountered in the practice ofemergency medicine and are presenting one of the most challenging problems to theattending surgeons or physicians in the emergency out patients’ department. Fractures ofthe facial skeleton are associated with variable morbidity, disfigurement and functionaldeficits. More than 50% of these patients have multi-system trauma requiring coordinatedmanagement between physician, otorhinolaryngologist, trauma surgeon, ophthalmologist,dentist, oral and facio-maxillary surgeon and neurosurgeons altogether. Maxillofacialtrauma includes injuries to any of the bony or fleshy structures of the face. A fracturednose or jaw may affect the ability to breathe or eat. Any maxillofacial injury may alsoprevent the passage of air or be severe enough to cause a concussion or more seriousbrain damage.

Road traffic accidents are reported to be the most common causes in developingcountries whereas interpersonal violence is the leading causes in the developed countries1. .With regards to the anatomical sites, mandibular and zygomatic complex fracturesaccount for the majorities among all types of facial fracture2. .Males are morepredominant sufferer than females. Their occurrence varies according to the mechanismof injury and demographic factors like sex, age, race, geographic distribution, culture,socioeconomic status and road safety regulations2. The trauma to this region is very muchconcerned with function of the various special organs like eyes, ear, nose, mouth, andvital structures of head and neck .Also the psychological impact of disfigurement afterthe injuries can be devastating.

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ANATOMICAL CONSIDERATIBONS

The maxillofacial region is divided into three different parts.A. Upper face –This includes frontal bone and sinusB.Midface—The midface contains the nasal bones, ethmoid, zygoma and maxilla. This isdivided into upper and lower parts.

Upper part – (a) That part of maxilla where LeForte II and LeForte III fracturesoccur and (b) Nose, Nasoethmoid complex, Zygomatico-maxillary complex and orbit.

Lower part- Where LeForte I fracture occurs.C.Lower face-This part includes the mandible having its condyle, ramus, angle, body,symphysis, alveolar part and coronoid process.

Upper face

Midface

Lower face

Figure -3. Showing frontal view of the skull

The orbitThe orbit needs separate description because of its complexity in formation. The parts

of the orbit are:-(1)Superior orbital margin –This is formed by the frontal bone.(2)Lateral orbital margin-This is formed by frontal process of zygoma, the zeugmaticprocess of frontal bone and greater wing of sphenoid.(3)Inferior orbital margin – This is formed by zygoma and maxilla.(4)Medial orbital margin- This is formed by frontal process of maxilla, lacrimal bone,angular and orbital processes of frontal and ethmoid bones.(5) The orbital floor is formed by the roof of maxilla.

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(6) The apex –this is formed by the lesser and greater wing of sphenoid, palatine and partof ethmoid.

midface

Upper face

Lower face

Figure -4. Lateral view of the skull with subdivisions

Figure -5. The orbit

THE NERVESThe maxillofacial area is innervated or related by all cranial nerves, but major

innervations are from the Trigeminal nerve, facial nerve and great auricular nervethrough thrie branches.Trigeminal nerve1. Ophthalmic division- first division of trigeminal nSensory supply- to the skin of forehead, upper lid and conjunctiva.Branches – i.lacrimal n., ii.supraorbital n., iii.supratrochlear n., iv.external laryngeal n.,v.nasocilliary n. and vi.frontal n

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2. Maxillary division-second division of trigeminal nSensory supply- to the skin of part of nose, lower eye lid, cheek and upper lip.Branches— i.infraorbital n., ii.zygomaticofacial n., iii.zgomaticotemporal n. andiv.anterior and posterior alveolar n.3. Mandibulardivvision- third division of trigeminal nMotor supply to the muscles of masticationSensory supply- to the skin of lower lip, chin, temporal area, and part of auricleBranches- i. lingual n., ii.inferior alveolar n., iii.zygomaticofacial n., iv.dental n.v.mentaln.,vi. Buccal n., vii.auriculoteporal n.Facial nerveThe facial nerve supplies motor innervations to all muscles of facial expression throughthe branches like:-a.zygomaticofacial and b.faciocervical branchesGreater auricular nerveThis is a branch of cervical plexus that supplies the angle of the mandible, and skin overthe parotid and mastoid process.Other cranial nerves.CN-I-Olfactory n.-For smellCN-II-Optic n.-For visionCN-III-Occulomotor n.-For eye ball movement with superior, medial and inferior recti,inferior obliqe, levator palpebrae, pupilloconstrictor and cilliary muscles.CN-IV-Trochlear n.-Eye ball movement through innervation of superior oblique.CN-VI-Abducens n. Eye ball movement through innervation of lateral rectus.CN-VIII-Vestibulocohlear n. - For hearing and balanceCN-IX-Glossopharyngeal n.-For taste, swallowing and salivation.CN-X-Vagus n.- For taste ,swallowing and palate elevationCN-XI-Spinal accessory n. - Head rotation and shruggingCN-XII-Hypoglossal n.-Movement of tongueBLOOD SUPPLYThe face is highly vascular area of the body and is mainly supplied with branches ofexternal carotid artery through the lingual, facial, internal maxillary and superficialtemporal arteries. and venous drainage is through superficialtemporal,pterygoid,retromandibular , lingual ,facial, and external jugular veins.INCIDENCE AND PREVALENCE

Information regarding the demographic distribution of the maxillofacial injuriesdepends very often upon various factors like country, location of trauma centre, reportingfacilities available, urban or rural age groups, sex and overall influence implication ofrule and regulation of the land in respect of traffic, labor acts and child abuse etc.on itspopulation. Universally many literatures show that the most active period of life i.e.second to third decade of life is the commonest age group to be affected by maxillofacialinjuries 4,7,8..Youth are frequently involved in high speed transportation ,out door contactsports and engage acts of affray 8. In a study ZA Rana et.al. (2010) pointed out that about73% patients were males, signifying the male gender predominance which is alsoconsistent with literatures from around the world 4,5,6 . Falls account for 78 percent offacial injuries in preschoolers and 47 percent of such injuries in children between the agesof six and 15. In older adolescents and adults, violent crime or other personal assaults

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account for almost 50 percent of facial injuries, with automobile accidents accounting for29 percent and sports-related accidents for another 11 percent. Patients between the agesof 17 and 30 are more likely to suffer facial injuries from gunshot wounds, while olderadults are more likely to be injured by attacks with blunt objects. About 10 percent offacial injuries in young children are caused by parental abuse. Children who grow up onfarms are at significant risk for injury by animals 3.

AETIOLOGYIn a study ZA Rana et.al.(2010) demonstrated that road traffic accidents accounts

maximum (57 %)followed by fall (11%),and natural disaster (10%) 4 .In urban setupcommunity causes of facio maxillary trauma are mostly due to assaults, road trafficaccidents , zygomatic and mandible are most commonly encountered fractures due toassaults. In community and rural set up population motor vehicle accidents, assaults,recreational activities, accidents are the main causes for facio maxillary trauma. Othercauses of facio maxillary trauma include falls from the height, sports injury, gunshots,fire arm injury, occupational, penetrating trauma, domestic violence, child abuse andnatural calamities. Some other studies as reported by Bataineh AB from Jordan (55%),Subhasraj,et.al.from India (62%),Laski R et.al.from USA (40%),Schatenaar k. et.al fromEngland (24.7%), Cheema F, from Pakistan (44%), and Leles JL Rodrigues et.al. fromBrazil(45.7%) also significantly denote that the road traffic accident is the single mostcommon etiological factor for causing the maxillofacial injuries7,9,10,11,12,13. . In pediatricage groups the causes of facial trauma include falls (most common), blunt trauma, bysports activities, motor vehicles accidents, assaults, non-accidental trauma, and childabuse. In children maxillofacial trauma is associated with soft tissue injury (mostcommon), injury to cervical spine and, intracranial injury 3.Okoje,Alonge,oluteye,et.al intheir study on changing pattern of pediatric maxillofacial injuries in Ibadan, Nigeriademonstrated that the RTA scored highest among all etiological factors (54.5%) followedby falls (35.8%) from height causing maxillofacial injuries 14 .

PATHOPHYSIOLOGY

The kinetic energy present in a moving object is a function of the mass multiplied by thesquare of its velocity. The dispersion of the kinetic energy during deceleration producesthe force that results in injury .High impact and low impact forces are defined as greateror lesser than the 50 times the force of gravity. The supra orbital rim, symphysis andcondyle and angle of mandible and frontal bones require a high impact force to bedamaged and zygoma, and nasal bones require low impact fore to be damaged 15.

Contradictory to the adults, because of the differences in the proportion of a child’shead and skeleton, relative prominence of child’s cranium compared to the midface,together with the elasticity of the immature facial skeleton, the incidence of fractures offacial skeleton in children is very low. In comparison a child suffers more soft tissueinjury than maxillofacial trauma in the form of laceration, burn and electrical trauma.Considering the clinical aspects of maxillofacial trauma the high incidence of nasal andzygomatico-orbital complex fractures is obviously related to the prominent position ofthese structures within facial skeleton and their proximity to the external trauma 16, 17.

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Road traffic accidents are the main cause of dento-alveollar fractures especially inmotorbike accidents where security measures are neglected 18 .

Table -1

As far as mandible is concerned the most common site of mandibular fractures due toassaults is the mandible angle 19, 20 and greater incidence of condyle fracture is observedin traffic accidents 21 .The age associated risks of injuries resulting from falls differ intwo ways .In children it is due to incomplete motor development and greater craniofacialmass to body ratio that leads to greater incidence of maxillofacial injury 25,26. Whereas inelderly it is due to neuromuscular and motor limitations that leads to greater incidence ofmaxillofacial injury20,27.Different Fractures

A.UPPER FACEa. Frontal Bone and Sinus fractures

In frontal bone fractures which require severe blow to the forehead the anterior andposterior tables may be fractured and sometimes the dura may be teared in posterior tablefractures and nasofrontal duct is injured in anterior table fracture 22 .Fractures of frontalbone may occur in association with extensive facial injuries as a result of direct blunttrauma to the forehead in motor vehicle accidents ,sporting collision or assaults.b. Nasal bone fractures

Nasal bone fractures result in forces transmitted during trauma. Isolated nasal bonefractures are the most commonly seen fractures in facial trauma but this may beassociated with severe midface trauma involving naso-orbito-ethmoidal complex thefrontal sinus and orbito zygomatic complex. Nasal and zygomatico-orbital fractures aremostly due to RTA (road traffic accidents), and assaults 23,24.B.MIDFACE

Upper centrala. Orbital floor fractures

The orbital floor fracture can occur in isolation or in association with medial wallfracture .When a force strikes the globe or orbital rim, the intra orbital pressure increaseswith transmission of this force and damages the weakest aspect of the orbit, i.e the floorand medial wall .Herniation of the orbital contents into the maxillary sinus is possible.The incidence of ocular injury is high but globe rupture is rare.

FORCE REQUIRED FOR FACIAL BONE FRACTURES 28

BONE FORCE OF GRAVITY(g)Nasal bonesZygomatic bonesAngle of mandible bonesFrontal glabellar region bonesMidline maxilla bonesMidline mandible bonesSupra-orbital bones

30507080100100200

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b.Nasoethmoid complex fracturesThe fracture extends from the nose to the ethmoid and can result in damage to medial

canthus, lacrimal apparatus, nasofrontal duct, dura and cribriform plate.Lateral mid facec.Zygomatic arch fracture

This is caused by direct blow and can result in isolated fracture of zgomaticotemporalsuture. The arch tends to break at its weakest point which lies just posterior to thezygomatico-temporal suture line. A direct blow may cause fracture of the orbital floorproducing a blow out. The displacement is usually to the medial direction and canproduce trismus by interfering with coronoid process and temporalis muscles.If thetemporslis and masseteric fascia are disrupted the arch tends to collapse inferiorly.d.Zygonatico-maxxillary complex fracture

Zygomaticomaxillary complex fractures resulting from the direct trauma extend throughzygomtico-frontal and zygomatico-maxillary sutures .The fracture lines usually extendthrough the infraorbital foramen and orbital floor .Ocular injury is common .Thesefractures are also known as tripod fractures .Two factors usually govern the degree andtype of displacement of bone. First, the direction and site of the impact relative to the axisof the zygomatic bone and the second, the pull of the masseter and the integrity of thefascial attachments.Lower Central midfaceMaxillary fracturesThese fractures are traditionally divided into alveolar, LeForte I, II, III fractures as mostof them follow the lines of weakness.a. AlveolarThis can occur in isolation from a direct low energy force through the alveolar line.b.LeForte I(Guerin ) fracture or horizontal or transmaxillary fractureHere is a horizontal maxillary fracture that runs across the inferior aspect of maxilla andseparates alveolar process and hard palate from the rest of the maxilla .This extendsthrough the lower third of nasal septum, maxillary sinuses, inferior part of medial and

Fig .No.6 LeForte I(Guerin ) fracture Fig .No.7 LeForte I(Guerin ) fracture

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lateral pterygoid plates, and palatine bones resulting in a mobile maxilla with a stableupper midface.This complicates with loss of teeth infection and malocclusion.c.LeForte II (pyramidal) fractureDue to its triangular shape this is called a pyramidal fracture. This type of fractureinvolves separation through frontal process, lacrimal bone, floor of orbitzygomaticomaxillary suture line, lateral wall of maxillary sinuses, pterygoid plates.Maxilla and nose are mobile .This fracture involves the non union of fractured bones,obstruction to the tear duct and lacrimal gland, double vision and malocclusion .

Fig.No.8-LeForte II (pyramidal) fracture Fig.No.9-LeForte II (pyramidal) fracture

d. LeForte III or Craniofacial disjunction or dislocation.This is a very severe kind of fracture and may be associated with severe skull and braininjury. The fracture results in separation of all facial bones of midface from base of skullat the level of nasofrontal suture line with simultaneous fracture of zygoma, maxilla andnasal bones.The fracture lines run posterior inferior to the optic foramen, across the lesserwing of sphenoid, to pterygomaxillary fissure and sphenopalatine foramen. The fracturealso traverses the medial wall of orbit, to the superior orbital fissure, greater wing ofsphenoid, zygomatic bone and zygomaticofrontal suture line. There is mobility ofcomplete midface which is detected at the frontonasal and frontozygomatic suture lines.The displacement is downward and backward along the base of skull imparting a dishface deformity and few may be associated with midline palatine fracture.

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a bFig.No.10 a,b - LeForte III or Craniofacial disjunction or dislocation

C. LOWER FACEFRACTURES OF THE MANDIBLEThe fractures of lower face involves the fractures of the mandible which present withseveral patterns and combinations of fracture and each is determined by the magnitude ofthe impact, the direction of the blow, the age of the patient, state of the jaws andcondition of dentition..The weakest part of the mandible is the subcondylar region and isthe therefore most common site of fractures.The most usual combinations of mandibular fractures are as:-More commons

a. # bilateral subcondylar regionsb. # of body and opposite anglec. # of body with contra lateral condyle

Less commonsd. # of bilateral anglee. # of bilateral bodyf. Comminuted #s

Rowe and Killey's classificationA.Fractures not involving the basal bone—are termed as dentoalveolar fractures.B. Fractures involving the basal bone of the mandible.

Subdivided into following.i.Single unilateral

ii. Double unilateraliii. Bilaterally.iv.Multiple.

Dingman and Natvig's classification by anatomic regiona.Symphysis fracturesb.Canine region fracturesc.Body of mandible fracturesd.Angle region fracturese.Coronoid region fracturesf.Condyle fracturesg.Dentoalveolar fractures

The incidence of fractures of mandible as far as the sites are concerned is given below.1. Condylar 2.Subcondylar 3.Coronoid 4.Angle 5 .Body 6. Symphysis and

parasymphys

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2%

36%

20%

15%21%

Figure No-11-. Showing parts of the mandible with incidence of proneness offactures

Pathological Types of mandibular fracture1. Simple:-closed fracture -there is fracture without injury to skin or mucosal lining2. Compound:-open fracture-here the fracture communicates externally through

skin or mucosal lining.3. Multiple;- two or more fractures4. Indirect:-Fracture site is distant from the site of injury.5. Complex:-the fracture may be single or compound with significant tissue injury.6. Comminuted:- fracture with crushed bone.7. Green stick: - incomplete fracture in which one cortex is fractured and other

cortex is intact.8. Pathological:-there is fracture from mild injury due to existing bone disease.9. Impacted: - after fracture one segment is driven into the other one.10. Atrophic: - fracture due severe atrophy of bone.

Displacements in different types of mandibular fractures# Condyl --there occurs anteromedial rotation of condyl secondary to the pull due

to lateral pterygoid muscles.

Fig. No 12:-Left sub-condylar # Fig. No 13:-Left sub-condylar

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Fig. No14 :- Bilateral sub-condylar # Fig. No15 :- Left sub-condylar #

Fig. No-16 : Bilateral sub-condylar ## Angle of mandible.--

The factors responsible for the pull are:-1. Posterior segment is pulled to medially, upward and forward by masseter, medial

pterygoid and temporalis .muscles.2. Direction of the fracture lies in vertical or horizontal plane.

When the muscle pull resists the displacement of the fragments then the fracture line isconsidered favorable fractures. When the muscle pull distracts the displacement of thefragments then the fracture line is considered unfavorable fractures.Therefore,

(a) Fractures running forward from lingual to buccal aspect resist medialdisplacement and are known as vertically favorable fractures.

(b) Fractures running backward from buccal to lingual aspect lead to easydisplacement lingually and are known as vertically unfavorable fractures

(c) Fractures running from superior border of mandible forward to inferior marginresist upward displacement - horizontally favorable fractures.

(d) Fractures running from opposite to the above distract the fragments more and areknown as horizontally unfavorable fractures.

# Body of mandible:-There is medial displacement of posterior segment due to mylohyoid muscle pull.

MANAGEMENT PROTOCOL OF THE FACIOMAXILLARY INJURIESA. PRIMARY SURVEY AND MANAGEMENT

In Maxillofacial Injuries as well as in all aspects of trauma management the primaryaim is to establish the patient’s vital functions first than to go for immediate definiteclinical examination of the patient as soon as the patient reports to the out patientdepartment, as the maxillofacial injuries can endanger the air way and are often

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associated with brain damage, chest injuries, and visceral injuries especially in high forceimpacts as it is in road traffic accidents .Therefore in maxillofacial injury first ensure theadequate air way and ventilation ;look for abdomen, thorax and neck regions ;assess thelevel of consciousness and also look for whether there is any features of shock .

All the protocols for evaluation and management of an endangered patient should bemaintained as per ABCDE (Airway, Breathing, Circulation, Disability/Drgs, ExposureOr Environment Control) of primary care. The primary care is the rapid identification andtreatment of life-threatening injuries such as air way obstruction, tension or openpneumothorax, flail chest, massive hemorrhage and cardiac tamponade.It should be quickand complete. Further detailed examination for definitive treatment of facial injury musttake the secondary place.

a. The need for airwayIt is carefully considered in both the conscious and comatose patient in those who

has compromised airway such as posterior displacement of tongue secondary to themandibular fractures or posteroinferior displacement of the maxilla with middle third offace injuries. Non- surgical procedures for maintaining the airways like 1.Chin lift 2.Jawthrust 3.Oropharyngeal airway 4.Nasopharyngeal airway 5. Orotracheal intubation6.Nasotracheal intubation may be required

If no cervical spine injury is suspected attempts to open the air way may be madecarefully with head tilt or chin lift maneuver and avoid over extension by pulling thepatient in neutral position for infants and sniffing position for children. In case if acervical spine injury is suspected the jaw thrust technique is preferred. Middle thirdfracture may be reduced immediately by hooking the fingers of one hand around theposterior margin of the patient’ hard palate and pulling the displaced jaw forward. Thesepatients may progress rapidly to severe air way compromising state due to oropharyngealoedema.

Therefore middle third facial factures as well as paradoxical chest movement due toflail chest require endotracheal intubation (Orotracheal intubation /Nasotrachealintubation). Blood, vomitus, tooth fragments, and foreign body may obstruct the airwayand clearance of all debris is a priority.

A displaced tongue secondary to comminuted anterior mandibular fracture may alsocompromise the airway which may be taken care of. If the patient’s tongue or lower jawshas fallen backwards then put some suture or towel clip through it and gently pull itforwards. The patient is allowed to lie down on his side. If patient’s soft palate has beendriven onto his tongue then hook your fingers around the back of his hard palate and thenthe middle of the face is gently pulled upward and forwards so that the airway is restoredproperly. But if fracture segments are impacted and it is failed to reduce thentracheostomy is essentially needed to save the life. This disimpaction is done bygripping the patient’s alveolus with Rowe’s forceps and is rocked to disimpact themaxillary fragments. If the patient has severe jaw injury with much tissue loss thentransport the patient on the stretcher on his front in prone position while the head slightlyhanging from the end of the stretcher and forehead is supported by bandages between thehandles of it .

If the patient’s nose is more severely injured and there is bleeding then the blood issucked out and a oropharyngeal airway or nasopharyngeal tube is inserted down one

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side and that is regularly sucked out with a suction machine. to prevent blockage. Buthowever if reduction of middle thud face is not possible immediately; if severe posteriorthird bleeding is not controllable ;edema of glottis following neck injury ,then atracheostomy should immediately required under local anesthesia and a cuffed PVCtracheostomy tube is put.b.Control of bleeding and maintenance of circulation

Origin of hemorrhage may be detected and managed .Shock due to hemorrhagemostly due to trauma to internal structures rather than facial injury .Nasal bleeding can becontrolled by adrenaline nasal packing. Other source of bleeding may be searched andmust be stopped. Circulation should be maintained. The patient’s level of consciousness,skin color and character of pulse will provide regarding his or her status. In injury withno source of external bleeding is evident and patient is in shock then a probable cause ofbleeding from internal organs like thorax, abdomen ,retro peritoneum or from thigh fromfemur fracture may be sought for.c.Assessment of head injury

After restoring adequate air way, circulation and establishing good haemostatic statusassessment of head injury is carried out. which is usually recorded by Glasgow ComaScore which is referred as the following.Glasgow Coma Score

The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composedof three parameters: Best Eye Response, Best Verbal Response, and Best MotorResponse, as given below:

A.Best Eye Response. (4)1. No eye opening.2. Eye opening to pain.3. Eye opening to verbal command.4. Eyes open spontaneously.

B.Best Verbal Response. (5)1. No verbal response2. Incomprehensible sounds.3. Inappropriate words.4. Confused5. Orientated

C.Best Motor Response. (6)1. No motor response.2. Extension to pain.3. Flexion to pain.4. Withdrawal from pain.5. Localising pain.6. Obeys Commands.

Note that the phrase 'GCS of 11' is essentially meaningless, and it is important to breakthe figure down into its components, such as E3V3M5 = GCS 11.A Coma Score of 13 or higher correlates with a mild brain injury; 9 to 12 is a moderateinjury and 8 or less a severe brain injury.

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This gives a reliable, objective way of recording the conscious state of a person. It canbe used by medical and nursing staff for initial and continuing assessment. It has value inpredicting ultimate outcome. Three types of response are independently assessed and arerecorded on an appropriate chart (and the overall score is made by summing the scores).The calculator has been adapted to estimate the Glasgow verbal score from the Glasgoweye and motor scores in intubated patients. There is a Paediatric Glasgow Coma Scaleapplicable to infants too young to speak - and the equivalent infant responses are given inthe various sections below.

Table-2Glasgow Coma Score for paediatrics 29

Characters Scoring

1. Best Motor Response (M) - 6 gradesApply varied painful stimulus: trapezius squeeze, earlobe pinch, supraorbital pressure, sternal rub, nail-bedpressure etc:

1. No response to pain.2. Extensor posturing to pain: The stimulus causes limb extension (abduction, internal rotation of shoulder,

pronation of forearm, wrist extension) - decerebrate posture.3. Abnormal flexor response to pain: Stimulus causes abnormal flexion of limbs (adduction of arm, internal

rotation of shoulder, pronation of forearm, wrist flexion - decorticate posture.4. Withdraws to pain: Pulls limb away from painful stimulus.

Infant: withdraws from pain.5. Localizing response to pain: Purposeful movements towards changing painful stimuli is a 'localizing'

response.Infant: withdraws from touch6. Obeying command: The patient does simple things you ask (beware of accepting a grasp reflex in this

category).Infant: moves spontaneously or purposefully

2. Best Verbal Response (V) - 5 gradesRecord best level of speech. If patient is intubated, a "derived verbal score" is calculated via a linear regressionprediction.

1. No verbal response.2. Incomprehensible speech: Moaning but no words.

Infant: Inconsolable, agitated.3. Inappropriate speech: Random or exclamatory articulated speech, but no conversational exchange.

Infant: Inconsistantly inconsolable, moaning.4. Confused conversation: Patient responds to questions in a conversational manner but some

disorientation and confusion.Infant: Cries but consolable, inappropriate interactions.5. Orientated: Patient 'knows who he is, where he is and why, the year, season, and month.Infant: Smiles,

orientated to sounds, follows objects, interacts3. Best eye response (E) - 4 grades

1. No eye opening;2. Opening to response to pain to limbs as above3. Eye opening in response any speech (or shout, not necessarily request to open eyes);4. Spontaneous eye opening.

Glasgow Coma Scale Score (max 15): (DerivedVerbalscore:)

Interpretation of Symptoms: (Severe: 8 or less; Moderate: 9-12; Mild: 13 or more)

d.Examination of EyesInspection

Look for penetrating injuries, corneal abrasion, and dislocation of lens, lacerationinvolving the lacrimal apparatus, exophthalmos or enophthalmos or fat protruding from

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the globe. In conscious patient visual acuity, ophthalmoscopic examination for retinaldamage and ischaemia, light reflexes, external eye movements ,interpupillary distance,papillary size and shape etc are to be inspected .Evert the eye lids and check for foreignbodies or laceration. Raccoon eyes (also known in the UK as panda eyes) or periorbitalecchymosis is a sign of basal skull fracture 30 .Bilateral subconjunctival hemorrhageoccurs when damage at the time of a facial fracture tears the meninges and causes thevenous sinuses to bleed into the arachnoid villi and the cranial sinuses. Pain and swellingare the most common signs and symptoms of a black eye.. Raccoon eyes may beaccompanied by Battle's sign, an ecchymosis behind the ear. If the patient has massiveproptosis it may be due to severe retrobullbar hemorrhage due to fracture of skull basecausing blindness compressing his optic nerve. (Make a small incision at outer canthusand take a haemostat and push onto the incision. This may prevent his blindness.) Adisplacement of eye ball downwards and inwards indicates herniation of the contentsthrough the floor of the orbit into maxillary sinus or a fracture of zygomatico-fronto –maxillary complex. .Examine for presence of diplopia by separating the eye lids. Othersigns of more serious injury are double vision, loss of sight, loss of consciousness,inability to move the eye, blood or clear fluid from the nose or the ears, blood on thesurface of the eye itself and persistent headache. Examine the anterior chamber forpresence of blood in anterior chamber. Tenderness on Palpation on medial orbital areasignifies damage to the nasoethmoidal complex. On palpation examine for Forcedduction (test) to see for the avulsion of the medial canthal ligament which produces anabnormal slant of palpebral fissure if positive. Also perform traction test for status ofmedial canthal ligament attachment by grasping the lower eye lid and pulling against itsmedial attachment. If the test gives of then there is obvious medial canthal disruption.

e. Examination of NoseUnilateral epistaxis without presence of direct nasal injury may indicate fracture of

maxillary antrum. Look for the facial asymmetry; compare one side of the face with otherside and also find whether nose or face is flattened. Inspect for telecanthus and palpatefor tenderness or dislocation. Inspect the nasal septum for hematoma, deviation, mucosallaceration ,fracture or CSF leak . Perform bimanual nasal palpation test by pressingthe anesthetized nasal cavity with a finger against medial orbital rim and simultaneouslypressing the medial canthus. If bone moves then the nasoethmoidal complex is fractured.Put a hand on anterior nasal bridge and another on bridge of nose and feel for mobility.If only teeth do move then it is LeForte I fracture and if both nose and maxilla movetogether then it may be LeForte II or III fractures.

f.Examination of EarsInspect the ear canal for laceration, CSF leak, integrity of tympanic membrane

hemotympanum, perforation or mastoid area ecchymosis (Battle’s Sign).g.Examination of Tongue and oral cavity

Inspect for intra oral laceration, ecchymosis, and swelling .Bimanually palpate formandible for its mobility, integrity, tenderness and crepitus.Palpate each toothindividually for movement ,pain ,gingival and intraoral bleeding ,tears andcrepitus.Perform the tongue blade test by asking the patient to bite hard on a tongueblade and if the patient can not bite then the jaw is fractured.

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h.miscellaneus approach Do not move the damaged or broken facial bones at first instance; otherwise it

will make the situation worse. Wound decontamination and debridement. Wound assessment –for assessing the injury to the major blood vessels, nerves,

ligamentsjoints, bones or internal organs. Wound exploration and closure- after the patient is all stable. X-rays of chest to exclude any thoracic injury.

i.Medical therapya. Antibiotics – For fractures with dural tears or CSF leaks the drug of choice isvancomycin and ceftazidime. For comminuted sinus fractures the drug of choice isamoxicillin-clavulanic. For facial laceration the drug of choice is ceftriaxone and for oralcavity laceration the drug of choice is clindamycin.b.Pain management.c.General medical therapy –administration of oxygen, intravenous fluids ,bloodtransfusion and tetanus prophylaxis.

B. SECONDARY SURVEY AND CLINICAL FEATURES OF THE FACIOMAXILLARYINJURIES

After the patient is stabilized from the initial air way distress, haemorrhage or shockthen the secondary survey or final assessment of the injury to detect the type, depth,extent and degree of injuries is done for further management. The optimal time fordefinitive treatment is between 5th to 8th post traumatic day during which theinflammatory swelling would have been subsided and patient’s general medical conditionwould have been improved. And it also allows sufficient time to assess the fracture, tomake splints if required. Wash the face with warm water or saline water to remove thecaked blood for better assessment of injuries.CLINICAL FEATURES OF INDIVIDUAL FRACTURES

a.Frontal bone fractures.

Disruption or crepitus of the supraorbital rims Subcutaneous emphysema. Paresthesia of supraorbital and supratrochlear nerve distribution Soft tissue edema over the frontal region, periorbital echymosis and

edema Soft tissue contusion or laceration over frontal sinus area Epistaxis or CSF rhinorrhoea.

b.Nasal bone fractures.Isolated nasal fractures are the most commonly seen fractures in facial traum.However

these may be associated with severe mid facial trauma involving the naso-orbito-ethmoidal complex ,frontal sinuses , the orbito- zygomatic complex or isolated nasalbone fractures . The fractures of nasal bones are classified into three following classes.

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Class –I or Chevallet Fracture:-Here the fracture line runs through the nasal bone andproximal part of the quadrilateral cartilage the vertical fracture that runs on the septum isknown as Chevallet fracture.Class –II fracture:- This involves the fracture of nasal bone perpendicular plate ofethmoid, vomer and quadrilateral cartilage.Class –III- fracture:-When the fracture extends to include the ethmoid labyrinth, thenperpendicular plate along with ethmoid air cells are pulled backward causing a pig likeappearance with forward facing nostril and saddling.The fracture of nasal bone may be complicated with, deviated nasal septum, bleeding,saddling, CSF leak and orbital complications like hypertelorism, diplopia, damage tolacrimal sac and nasolacrimal duct, dacryocystitis and blindness.

a bFig.No.17 a,b -A 3-D reconstructed CT scan of skull showing FNOE fractures.

a bFig.No.18 a,b -FNOE fracture of same patient : pig like appearance

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c.Orbital fracture1. A black eye, with swelling and black and blue discoloration around the injured

eye; possible redness and areas of bleeding on the white of the eye and on theinner lining of the eyelids

2. Double vision, decreased vision or blurry vision3. Difficulty in looking up, down, right or left4. Abnormal position of the eye (either bulging out of its socket or sunken in)5. Numbness in the forehead, eyelids, cheek, upper lip or upper teeth on the same

side as the injured eye, possibly related to nerve damage caused by the fracture6. A puffy accumulation of air under the skin near the eye, usually a sign that the

fracture has broken through the wall of a sinus cavity, particularly the maxillarysinus.

7. Swelling and deformity of the cheek or forehead, with an obvious dent over thearea of broken bone

8. An abnormally flat-looking cheek, and possibly severe pain in the cheek whenyou attempt to open your mouth

d.Orbital floor fracture or blow out fractures

The orbital floor fracture can present Periorbital edema,Crepitus ,Echymosis,Enophthalmos ,Ocular injury ,Anesthesia or paresthesia of cheek and upper gum onaffected side ,Lateral and upward gaze dysfunction due to medial and lateral rectusentrapment,Diplopia as patient gazes upward due to entrapment of inferior rectus muscle.In trap door type orbital floor fracture leading to entrapment may cause nausea,vomiting, bradycardia hypothermia and pain in the eye (oculocardiac reflex).

e.Zygomaticomaxillary complex fracturesThe Zygomaticomaxillary complex fractures can present in the following ways:-Orbital features

Periorbital swelling Ecchymosis Subconjuctival haemorrhage Diplopia secondary to extra ocular dysfunction. Enophthalmos Paresthesia in infra orbital N distribution Palpable depression of orbital rim and zygomatic arch Step defect –palpated along the infraorbital rim or zygomatico maxillary suture.

Nasal and zygomatic features Loss and flattening of zygomatic body prominence Epistaxis Tenderness of frontozygmatic suture line Trismus due to impingement of coronoid process of mandible Intraoral eccymosis epistaxis Flame sign may be present due to dispersion and depression of the lateral canthal

tendon

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f.Zygomatic arch fractureThis fracture exhibits a palpable defect over the area involved, with pain on

palpation. There is limitation of movement of mandibleg.Maxillary factures

The maxillary facture are more common in adults than in children. The maxilla inchildren are proportionately smaller and denser than the adults with a relative lack ofsinus development .Therefore isolated displacement of part of or all of the maxillarycomplex is rare. In children however when fracture do occur then there are generallymore extensive craniofacial injuries with skull fracture, CSF rhinorrrhoea andcervical sine injuries.Clinical features of maxillary fractures are as follows:-1. Bilateral periorbital or circumorbital swelling and ecchymosis.2. Bilateral subconjuctival haemorrhage3. Facial deformity, asymmetry, flattening or elongation.4. Inraorbital paresthesia5. Palpable step deformity of infra orbital margins and tenderness at

frontozygomatic sutures.6. Malocclusion7. CSF rhinorrhoea8. Mobility of maxilla at different levels usually representing three recognizable

patterns of fractures namely LeForte-I, II, &III.9. LeForte-I,-Maxilla is mobile to the level of the base of the nose with a stable

upper midface.10. LeForte-II- Maxilla and nose are mobile as one unit with the movement detected

at fronto-orbital rims.11. LeForte-III- Mobility of complete midface with movement detected at the

frontonasal and frontozygomatic sutures.12. Midline palatal fractures result in independent movement of the right and left

maxilla , laceration of palatine bone and floating palate and teeth.

h.Mandibular facturesBody, angle and smphysis

1. Step deformity –palpable externally and orally2. Asymmetry of lower dental arch and derangement o occlusion3. Pain ,paradoxical movement and crepitus on distribution of fracture

segment4. Hematoma in buccal sulcus or floor of mouth5. Blood stained saliva6. Anaesthesia in mental nerve distribute

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Fig no19- symphysis fracture of mandible Fig no20- symphysis and angle fractures

i.Condyle fracture1. Temperomandibular joint tenderness2. Trismus3. The deviation of the jaw towards the injured side on opening of mouth4. Inability to move the mandible to the side opposite to the injury.5. The deviation of the jaw towards the injured side on rest with anterior open

bite secondary to the gagging .6. Symmetrical anterior open bite on bilateral fractures f the necks of the

condyle.C. INVESTIGATIONS and WORK UP

Laboratory studyComplete blood count every four hours to follow hemoglobin and hematocrit ;Sequential multiple analysis of 20 chemical constituents (SMA-20); Bloodgrouping and cross matching ,coagulation studies and tests for hepatitis and HIVare to be done routinely .CSF study of nasal discharge if suspectedImaging studyUpper face:-The study of choice is axial or coronal CT scan .Alternate studiesinclude x-rays of skull in Water’s view.Mid face:- The study of choice is axial or coronal CT scan.. Alternate studiesinclude x-rays of skull in Water’s view, posteroanterior and submentovertexviews and occlusal views.Lower face- The study of choice is Pantomographic X-rays. Alternate studiesinclude x-rays of Posteroanterior view, right and left lateral oblique views ofmandible, elongated Towne projection and occlusal X-rays. For condylar fractureCT scanning is strongly recommended.3-D CT reconstruction if possible.For temperomandibular joint injury and CSF leak- MRI is the choice ofinvestigation.

D. DEFINITIVE TREAMENTSi. Frontal bone fracture

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a. Non displaced anterior sinus wall fracture –observation and antibioticsb. Displaced anterior sinus wall fracture with severe comminution andmucosal injury – bone grafting and frontal sinus obliteration byotolarngologist, maxillofacial surgeon or plastic surgeon.c. Non displaced posterior sinus wall with CSF leak-may be observed for 5-7days and frontal sinus obliteration is done should the CSF leak persists.d. Displaced fractures of posterior wall without CSF leak with mildcomminution-osteoplastic flap and sinus obliteration surgery.e. Displaced fractures of posterior wall without CSF leak with more than 30%comminution-removal of posterior table by neurosurgeon.-cranialisation.f. Displaced fractures of posterior wall with CSF leak with minimal to mildcomminution - sinus obliteration surgery.g. Displaced fractures of posterior wall with CSF leak with moderate to severecomminution – cranialisation.h.

ii.Orbital floor fractureOrbital floor fractures require consultation with an ophthalmologist,

otorhinolaryngologist, oral and maxillofacial surgeon and plastic surgeon depending uponrequirements. Maximum Window period for repair of orbital floor is two weeks. Butpatients with oculocardiac reflex should undergo immediate exploration of the orbit.For isolated fracture of the orbital floor transconjuctival incision without canthotomy isideal where as for major isolated fracture of the orbital floor subcilliary approach. isindicated and repair is usually done with autologous bone graft or alloplasticmaterial..Indications for major fracture repair are :-

Defect of floor >50% Enophthalmos >2mm due to herniation in blow out fractures Diplopia on upward /downward gaze Positive forced duction test within 30% of primary gaze CT confirmation of

fracture .iii.Nasal bone fractures

Fracture of isolated nasal bone fracture is repaired by closed reduction of nasal boneand of septum by otolaryngologist within 5-7 days after swelling is subsided. The supportis given by intranasal packing and extra nasal splinting.iv.Nasoethmoidal fracturesThis requires a multi specialist approach.v.Zygomatic arch fractures.

Many of the zygomatic fractures do not need reduction in view of real risk of iatrogenicblindness following treatment in minimal defect..Reduction of zygoma can only done byopen reduction only.Temporal fossa approach.A skin incision is given just behind the hair line anterosuperior to the pinna and that is

developed through the fascia .A Rowe elevator is used to reduce the zygomatic archwhile not pressing on the parietal bone.

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Transcutaneous approachThe temporary fixation may be applied by packing the maxillary antrum through

Caldwell-Luc‘s approach or by silicon wedge supporting the lateral antral wall or aFolley catheter intranasally.vi. Zygomaticomaxillary complex fracturesOtolaryngologists,plastic surgeon and oral and maxillofacial surgeons should beconsulted for this type of fractures. The standard treatment is open reduction and fixationwith mini plates.vii.Maxillary fractures. PrincipleOtolaryngologists, plastic surgeon and oral and maxillofacial surgeons should be

consulted for this type of fractures .A principle in all Le Forte fractures is to reestablishthe premorbid dental occlusion. Portions of the pterygoid plates and associatedmusculature are still attached to the posterior portion of the maxilla, so passivemobilization of the fracture can be difficult. In isolated maxillary fractures, the stablecranium above and occlusal plate below provide sources of stable fixation. If available,dental cast, stereo lithographic models, and/or premorbid photographs may be usefulguides for treatment..Preoperative preparation

The patient should be informed about the risks and possible complications of theprocedure, possibility of temporary or permanent paresthesia, cerebrospinal fluid leak,meningitis, sinus infection or mucocele, anosmia, malocclusion, infection of implants,osteomyelitis, malunion or nonunion, external deformity, plate exposure, tooth injury,and the possible need for additional surgery due to treatment of maxillomandibularfixation (MMF).Operative plan and proceduresMMF is typically performed with arch bars and stainless steel 25- or 26-gauge interdentalwires. For edentulous patients, surgical splints or dentures secured to the underlying bonewith screws or with circummandibular and circumzygomatic wiring serve as the basis ofstabilization. The method of treatment is Open reduction and interaxillary fixation (whichis not used now-a-days.) followed by rigid fixation at pyriform rims andZygomaticomaxillary buttress. Internal fixation may be indicated with transosseous wirefixation, mini-plate fixation, or use of resorbale plate and screw fixation .Non –displaced,stable fractures with normal occlusion is managed conservatively. Displaced or unstablefractures are reduced and stabilized to restore functional occlusion, facial contour andsymmetry.In general treatment for LeForte and alveolar fractures external and internal fixation.Method applied for external fixation are, plastic head cap, Levant frame ,box frame andfacial tansfixation and for internal fixation are Internal wire suspension ,direct wiring,and miniplates .Le Fort I fracturesFor stable, non displaced Le Fort I fractures, MMF alone may suffice to provide stablerestoration of bony support. Unstable fractures require an additional means of fixation.The method of choice for fixation is through miniplates placed via an open approach. AGingivolabial incision through mucosa 5-10 mm labial to the apex of the sulcus is given.

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Fig 21-LeForte II fractures on AP view of X- Rays

Incision is extended down to alveolar bone from one molar region to the other. Elevatethe periosteum superiorly to expose the fracture lines not injuring the infraorbital N.Expose the nasomaxillary and zygomaticomaxillary buttresses, piriform aperture, andpremaxilla and nasal spine. Contour vertically oriented miniplates using a malleabletemplate to span the fracture line.Plating with low-profile titanium plates secured withmonocortical self-tapping screws across the nasomaxillary and zygomatico maxillarybuttresses are sufficient. In an alternative a 25- or 26-gauge wire is looped around thetemporal aspect of the zygomatic arch retrieved intraorally, and tightened to anintermediate wire loop connected to the arch bar..

1 2 3

46

5

Fig27-a complete tool box containing 1&3, screw driver2-screw holder,4-drill bit5&6-mini and llong plates

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1 2

3

4 56

Fig 28-a complete tool box containing 1&2 ,3 &4-mini and long plates,5&6 parts of thedrill bits.

1

2 3

4

Fig 29-a tool set containing 1& 2-stainless steel, 3-wire cutter, 4-wire twister

Le Fort II fracturesHere initial exposure is same as LeForte I. and extension of exposure is superiorly donefor adequate exploration of the orbital rim. This is achieved through subciliary ortransconjunctival incisions. More extensive degloving of the soft tissue envelope throughexposure of the piriform aperture and frontomaxillary region is facilitated by columellar-septal transfixion incisions. The pyramidal free maxillary segment is stabilized to theintact zygoma. Fixation is completed directly using noncompression miniplates. Accuratecontouring of the plates using malleable templates is important for reduction and fixation.

Fig no22- Le Forte II fractureMonocortical, self-tapping screws are ideal. Alternative to miniplates is interosseouswiring.

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Le Fort III fracturesIn Le Fort III fractures, the mobile segments of bone are stabilized to the stable mandiblebelow and cranium above. Initially, the maxilla must be disimpacted and MMFimplemented. Soft tissue incisions is made in the same locations as for Le Fort IIfractures. Lateral brow incisions, glabellar fold incisions, or bicoronal scalp flaps can beused for additional exposure to the frontozygomatic buttress. Miniplate fixation iscurrently the most reliable and rigid method. Malleable templates; accurate contouring ofplates; and monocortical, self-tapping screws are used.. Bilateral zygomaticofrontalfixation is sufficient. Additional points of fixation like, nasomaxillary, nasofrontal,inferior orbital rim, zygomatic arch may be required..Interosseous wiring and suspension wiring have been described for Le Fort III fracturesbut are less reliable. Extra skeletal fixation is not usually necessary for simple Le Fortfractures.viii.Mandibular Fractures

a.b.

Fig no 23- a,b :- showing symphysis fracture of mandible with platings

Different methods are:-a. Reduction

1.Closed reduction techniqueIntermaxillary fixationExternal pin fixation

2.Open reduction techniqueTransosseous wiringCompression plates

Fig 24-Digital X-rays of skull and mandible showing fracture of angle of mandible in left

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a b

Fig 25 -Parasymphysis fracture of mandible Fig 26-Orthopantomogram showing

b.Fixation or immobolisatio

Fig25-fracture of angle of mandible in left Fig26- 3-D reconstructed CT showing# ofmandible and zygoma

1.Osteosynthesis without intermaxillary fixation;Compression platesNon –compression platesMiniplatesLag screwsResorbable plates and screws

2 .Intermaxillary fixationa.bonded bracketsb.dental wiringc.arch barsd.cap splints

3. Intermaxillary fixation with osteosynthesisa. trams osseous wiringb. circumferential.external pin wiringc. externald. transfixation

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COMPLICATION OF SURGERIES OF MAXILLOFACIAL INJURIESAspiration ,Airway compression, Scars, Permanent facial deformity, Nerve damageChronic sinusitis, Infection, MalnutritionWeight loss, Nonunion or malunion of fracturesMalocclusion or HaemorrhagREFERENCES

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