Maxillofacial trauma

Pathognomonic clinical signs of traumatic tissue maxillofacial area in children.

Modern diagnostic methods. The principles of therapeutic tactics in injuries of the soft tissues of the face, teeth, bones. Diagnosis,

differential diagnosis and treatment of TMJ ankilosis. Modern principles of

treatment and rehabilitation of children with congenital maxillo facial area.

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Maxillofacial traumaMaxillofacial trauma

Management of Management of traumatized patienttraumatized patient

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Causes:Causes:△△ Road traffic accident (RTA)Road traffic accident (RTA) 35-60% 35-60%

Rowe and Killey 1968; Rowe and Killey 1968; Vincent-Towned and Shepherd 1994Vincent-Towned and Shepherd 1994

△△ Fight and assault Fight and assault (interpersonal violence)(interpersonal violence)Most in economically prosperous countriesMost in economically prosperous countries

Beek and Merkx 1999Beek and Merkx 1999

△△ Sport and athletic injuriesSport and athletic injuries

△△ Industrial accidentsIndustrial accidents

△△ Domestic injuries and fallsDomestic injuries and falls

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Incidence Incidence

Literatures reported different incidence in different Literatures reported different incidence in different parts of the parts of the WORLDWORLD and at different and at different TIMESTIMES

√ √ 11% in RTA (Oikarinen and Lindqvist 1975)11% in RTA (Oikarinen and Lindqvist 1975)

Mandible (61%)Mandible (61%) Maxilla (46%)Maxilla (46%) Zygoma (27%)Zygoma (27%) Nasal (19.5%)Nasal (19.5%)

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Factors affecting the high/low incidence of Factors affecting the high/low incidence of maxillofacial traumamaxillofacial trauma

GeographyGeography Fight, gunshot and RTA in developed and developing countries respectively Fight, gunshot and RTA in developed and developing countries respectively

(Papavassiliou 1990, Champion et al 1997)(Papavassiliou 1990, Champion et al 1997) Social factorsSocial factors Violence in urban states (Telfer et al 1991; Hussain et al 1994; Simpson & Violence in urban states (Telfer et al 1991; Hussain et al 1994; Simpson &

McLean 1995)McLean 1995) Alcohol and drugsAlcohol and drugs

Yong men involved in RTA wile they are under alcohol or drug effects (Shepherd Yong men involved in RTA wile they are under alcohol or drug effects (Shepherd 1994)1994)

Road traffic legislationRoad traffic legislation Seat belts have resulted in dramatic decrease in injury (Thomas 1990, as reflected in Seat belts have resulted in dramatic decrease in injury (Thomas 1990, as reflected in

reduction in facial injury (Sabey et al 1977)reduction in facial injury (Sabey et al 1977) SeasonSeason Seasonal variation in temperature zones (summer and snow and ice in midwinter) of Seasonal variation in temperature zones (summer and snow and ice in midwinter) of

RTA, violence and sporting injuries (Hill et al 1998)RTA, violence and sporting injuries (Hill et al 1998)

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Assessment of Assessment of traumatized patienttraumatized patient

This should not concentrate on the most This should not concentrate on the most obvious injury but involve a rapid obvious injury but involve a rapid

survey of the vital function to allow survey of the vital function to allow management prioritiesmanagement priorities

5% of all deaths world wide are caused by traumaThis might be much higher in this country

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Peaks of mortalityPeaks of mortality First peakFirst peak

Occurs within seconds of injury as a result of irreversible brain or Occurs within seconds of injury as a result of irreversible brain or major vascular damagemajor vascular damage

Second peakSecond peak

Occurs between a few minutes after injury and about one hour later Occurs between a few minutes after injury and about one hour later (golden hour)(golden hour)

Third peakThird peak

Occurs some days or weeks after injury as a result of multi-organ Occurs some days or weeks after injury as a result of multi-organ failurefailure

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Organization of trauma servicesOrganization of trauma services

Pre-hospital care (field triage)Pre-hospital care (field triage) Care delivered by fully trained paramedic in maintaining airway, controlling Care delivered by fully trained paramedic in maintaining airway, controlling

cervical spine, securing intravenous and initiating fluid resuscitationcervical spine, securing intravenous and initiating fluid resuscitation

Hospital care (inter-hospital triage)Hospital care (inter-hospital triage) Senior medical staff organized team to ensure that medical resources are Senior medical staff organized team to ensure that medical resources are

deployed to maximum overall benefitdeployed to maximum overall benefit

Mass casualty triageMass casualty triage

triage decisions are crucial in triage decisions are crucial in determining individual patients survivaldetermining individual patients survival

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Primary surveyPrimary surveyⒶⒶ Airway maintenance with cervical spine Airway maintenance with cervical spine

controlcontrol

ⒷⒷ Breathing and ventilationBreathing and ventilation

ⒸⒸ Circulation with hemorrhage controlCirculation with hemorrhage control

ⒹⒹ Disability assessment of neurological statusDisability assessment of neurological status

ⒺⒺ EExposure and complete examination of the xposure and complete examination of the patientpatient

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AirwayAirway Satisfactory airway signifies the implication of Satisfactory airway signifies the implication of

breathing and ventilation and cerebral functionbreathing and ventilation and cerebral function

Management of maxillofacial trauma is an Management of maxillofacial trauma is an integral part in securing an unobstructed airwayintegral part in securing an unobstructed airway

Immobilization in a natural position by a semi-Immobilization in a natural position by a semi-rigid collar until damaged spine is excludedrigid collar until damaged spine is excluded

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Is the patient fully conscious? And able to maintain adequate airway?

Semiconscious or unconscious patient rapidly suffocate because of inability to cough and adopt a posture that held tongue forward

Sequel of facial injurySequel of facial injury

Obstruction of airway

asphyxia

Cerebral hypoxia

Brain damage/ death

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Immediate treatment of airway obstruction in facial Immediate treatment of airway obstruction in facial injured patientinjured patient

△△Clearing of blood clot and mucous of the mouth and nares and head Clearing of blood clot and mucous of the mouth and nares and head position that lead to escape of secretions (sit-up or side position)position that lead to escape of secretions (sit-up or side position)

△△ Removal of foreign bodies as a broken denture or avulsed teeth which Removal of foreign bodies as a broken denture or avulsed teeth which can be inhaled and ensuring the patency of the mouth and can be inhaled and ensuring the patency of the mouth and oropharynexoropharynex

△△ Controlling the tongue position in case of symphesial bilateral fracture Controlling the tongue position in case of symphesial bilateral fracture of mandible and when voluntary control of intrinsic musculature is of mandible and when voluntary control of intrinsic musculature is lostlost

△△ Maintaining airway using artificial airway in unconscious patient with Maintaining airway using artificial airway in unconscious patient with maxillary fracture or by nasophryngeal tube with periodic aspirationmaxillary fracture or by nasophryngeal tube with periodic aspiration

△△ Lubrication of patient’s lips and continuous supervisionLubrication of patient’s lips and continuous supervision

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Additional methods in preservation of the airway in patient with Additional methods in preservation of the airway in patient with severe facial injuriessevere facial injuries

Endotracheal intubationEndotracheal intubation Needed with multiple injuries, extensive soft tissue destruction and for serious injury Needed with multiple injuries, extensive soft tissue destruction and for serious injury

that require artificial ventilationthat require artificial ventilation

TracheostomyTracheostomy Surgical establishment of an opening into the tracheaSurgical establishment of an opening into the trachea Indications: Indications: 1. when prolonged artificial ventilation is necessary1. when prolonged artificial ventilation is necessary 2. to facilitate anesthesia for surgical repair in certain cases2. to facilitate anesthesia for surgical repair in certain cases 3. to ensure a safe postoperative recovery after extensive surgery3. to ensure a safe postoperative recovery after extensive surgery 4. following obstruction of the airway from laryngeal edema4. following obstruction of the airway from laryngeal edema 5. in case of serious hemorrhage in the airway5. in case of serious hemorrhage in the airway

CircothyroidectomyCircothyroidectomy An old technique associated with the risk of subglottic stenosis development An old technique associated with the risk of subglottic stenosis development

particularly in children. The use of percutaneous dilational treachestomy (PDT) in particularly in children. The use of percutaneous dilational treachestomy (PDT) in MFS is advocated by Ward Booth et al (1989) but it can be replaced with PDT.MFS is advocated by Ward Booth et al (1989) but it can be replaced with PDT.

Control of hemorrhage and Soft tissue lacerationControl of hemorrhage and Soft tissue laceration Repair, ligation, reduction of fracture and Postnasal packRepair, ligation, reduction of fracture and Postnasal pack

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Cervical spine injuryCervical spine injury

Can be deadly if it involved the odontoid process of Can be deadly if it involved the odontoid process of the axis bone of the axis vertebrathe axis bone of the axis vertebra

If the injury above the clavicle bone, clavicle collar If the injury above the clavicle bone, clavicle collar should minimize the risk of any deteriorationshould minimize the risk of any deterioration

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Breathing and ventilationBreathing and ventilation Chest injuries:Chest injuries:

Pneumothorax, haemopneumothorax, flail segments, Pneumothorax, haemopneumothorax, flail segments, reputure daiphram, cardiac tamponadereputure daiphram, cardiac tamponade

signssigns

Clinical Deviated trachea

Absence of breath sounds

Dullness to percussionParadoxical movementsHyper-response with a large pneumothoraxMuffled heart sounds

RadiographicalLoss of lung markingDeviation of trachea

Raised hemi-diaphragmFluid levels

Fracture of ribs

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Emergency treatment in case Emergency treatment in case of chest injuryof chest injury

Occluding of open chest woundsOccluding of open chest wounds

Endotreacheal intubation for unstable flail chestEndotreacheal intubation for unstable flail chest

Intermittent positive pressure ventilationIntermittent positive pressure ventilation

Needle decompression of the pericardiumNeedle decompression of the pericardium

Decompression of gastric dilation and aspiration of Decompression of gastric dilation and aspiration of stomach contentstomach content

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Circulation Circulation

Circulatory collapse leads to low blood pressure, Circulatory collapse leads to low blood pressure, increasing pulse rate and diminished capillary increasing pulse rate and diminished capillary

filling at the peripheryfilling at the periphery

Patient resuscitationPatient resuscitationRestoration of cardio-respiratory functionRestoration of cardio-respiratory function

Shock managementShock managementReplacement of lost fluidReplacement of lost fluid

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Fluid for resuscitation:Fluid for resuscitation:☞☞Adequate venous access at two pointsAdequate venous access at two points

☞☞ Hypotension assumed to be due to hypovolaemiaHypotension assumed to be due to hypovolaemia

☞☞ Resuscitation fluid can be crystalloid, colloid or blood; Resuscitation fluid can be crystalloid, colloid or blood; ringer ringer lactatelactate

☞☞ Surgical shock requires blood transfusion, preferably with Surgical shock requires blood transfusion, preferably with cross matching or group O+cross matching or group O+

☞☞ Urine output must be monitored as an indicator of cardiac Urine output must be monitored as an indicator of cardiac out putout put

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Reduction and fixation will often arrest bleeding Reduction and fixation will often arrest bleeding of long durationof long duration

Pulse and blood pressure should be monitored Pulse and blood pressure should be monitored and appropriate replacement therapy is to be and appropriate replacement therapy is to be

startedstarted

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Neurological deficientNeurological deficient Rapid assessment of neurological disability is made by noting the Rapid assessment of neurological disability is made by noting the

patient response on four points scale:patient response on four points scale:

A Response appropriately, is AwareA Response appropriately, is Aware

V Response to verbal stimuliV Response to verbal stimuli

P Response to painful stimuliP Response to painful stimuli

U Does not responds, UnconsciousU Does not responds, Unconscious

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Glasgow coma scale (GCS)Glasgow coma scale (GCS)(Teasdale and Jennett, 1974)(Teasdale and Jennett, 1974)

Eye Eye openingopening

Motor Motor responseresponse

Verbal Verbal responseresponse

SpontaneousSpontaneous 44 Move to Move to commandcommand

66 ConverseConverse 55

To speechTo speech 33 Localizes to Localizes to painpain

55 ConfusedConfused 44

To painTo pain 22 Withdraw Withdraw from painfrom pain

44 GibberishGibberish 33

nonenone 11 flexesflexes 33 gruntsgrunts 22ExtendsExtends 22 nonenone 11nonenone 11

Score 8 or less indicates poor prognosis, moderate head injury between 9-12 and mild refereed to 13-15

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Exposure Exposure

All trauma patient must be fully exposed in a All trauma patient must be fully exposed in a warm environment to disclose any other hidden warm environment to disclose any other hidden

injuriesinjuries

When the airway is adequately secured the second When the airway is adequately secured the second survey of the whole body is to be carried out for:survey of the whole body is to be carried out for:

Accurate diagnosisAccurate diagnosis Maintenance of a stable stateMaintenance of a stable state Determination of priorities in treatmentDetermination of priorities in treatment Appropriate specialist referralAppropriate specialist referral

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Secondary surveySecondary survey

Although maxillofacial injuries is part of the secondary Although maxillofacial injuries is part of the secondary survey, OMFS might be involved at early stage if the survey, OMFS might be involved at early stage if the

airway is compromised by direct facial traumaairway is compromised by direct facial trauma

Head injuryHead injury Abdominal injuryAbdominal injury Injury to extremitiesInjury to extremities

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Head injuryHead injury

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

OpenOpen

Closed Closed

it is ranged from Mild concussion to brain deathit is ranged from Mild concussion to brain death

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Signs and symptoms of head injurySigns and symptoms of head injury Loss of consciousLoss of conscious OROR History of loss of consciousHistory of loss of conscious History of vomitingHistory of vomiting Change in pulse rate, blood pressure and pupil reaction to Change in pulse rate, blood pressure and pupil reaction to

light in association with increased intracranial pressurelight in association with increased intracranial pressure

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

Skull fractureSkull fracture Skull base fracture (battle’s sign)Skull base fracture (battle’s sign) Temporal/ frontal bone fractureTemporal/ frontal bone fracture Naso-orbital ethmoidal fractureNaso-orbital ethmoidal fracture

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slow reaction and fixation of dilated pupil denotes slow reaction and fixation of dilated pupil denotes a rise in intra-cranial pressurea rise in intra-cranial pressure

Rise in intercranial pressure as a result of acute Rise in intercranial pressure as a result of acute subdural or extradural hemorrhage deteriorate the subdural or extradural hemorrhage deteriorate the

patient’s neurological statuspatient’s neurological status

Apparently stable patient with suspicion of head injury must be Apparently stable patient with suspicion of head injury must be monitored at intervals up to one hour for 24 hour after the monitored at intervals up to one hour for 24 hour after the

traumatrauma

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Hemorrhage Hemorrhage

Acute bleeding may lead to hemorrhagic shock and Acute bleeding may lead to hemorrhagic shock and circulatory collapsecirculatory collapse

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

Fracture of the extremities (femur)Fracture of the extremities (femur)

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Abdomen and pelvisAbdomen and pelvis In addition to direct injuries, loss of circulating In addition to direct injuries, loss of circulating

blood into peritoneal cavity or retroperitonial blood into peritoneal cavity or retroperitonial space is life threatening, indicated by physical space is life threatening, indicated by physical

signs and palpation, percussion and auscultationsigns and palpation, percussion and auscultation

Management:Management: Diagnostic peritoneal lavage (DPL) to detect blood, Diagnostic peritoneal lavage (DPL) to detect blood,

bowel content, urinebowel content, urine Emergency laprotomyEmergency laprotomy

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Extremity traumaExtremity trauma

Fracture of extremities in particular the femur can Fracture of extremities in particular the femur can be a significant cause of occult blood loss. be a significant cause of occult blood loss.

Straightening and reduction of gross deformity is Straightening and reduction of gross deformity is part of circulation controlpart of circulation control

Cardinal features of extremities injuryCardinal features of extremities injury Impaired distal perfusion (risk of ischemia)Impaired distal perfusion (risk of ischemia) Compartment syndrome (limb loss)Compartment syndrome (limb loss) Traumatic amputation Traumatic amputation

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Patient hospitalization and Patient hospitalization and determination of prioritiesdetermination of priorities

Facial bone fracture is hardly ever an urgent procedure,Facial bone fracture is hardly ever an urgent procedure,simple and minor injury of ambulant patient may occasionally simple and minor injury of ambulant patient may occasionally

mask a serious injury that eventually ended the patient’s lifemask a serious injury that eventually ended the patient’s life

△ △ emergency cases require instant admissionemergency cases require instant admission△ △ conditions that may progress to emergencyconditions that may progress to emergency△ △ cases with no urgencycases with no urgency

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Preliminary treatment in complex Preliminary treatment in complex facial injuryfacial injury

Soft tissue lacerationSoft tissue laceration (8 hours of injury with no delay beyond (8 hours of injury with no delay beyond 24 hours)24 hours)

Support of the bone fragmentsSupport of the bone fragments

Injury to the eyeInjury to the eye As a result of trauma, 1.6 million are blind, 2.3 million are suffering 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 serious bilateral visual impairment and 19 million with unilateral loss of sight (Macewen 1999)of sight (Macewen 1999)

Ocular damageOcular damage Reduction in visual acuityReduction in visual acuity Eyelid injuryEyelid injury

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Prevention of infectionPrevention of infectionFractures of jaw involving teeth bearing areas are Fractures of jaw involving teeth bearing areas are

compound in nature and midface fracture may go high, compound in nature and midface fracture may go high, leading to CSF leaks (rhinorrhoea, otorrhoea) and risk leading to CSF leaks (rhinorrhoea, otorrhoea) and risk

of meningitis,of meningitis,and in case of perforation of cartilaginous auditory and in case of perforation of cartilaginous auditory

canalcanal DiagnosisDiagnosis: : Laboratory investigation, CT and MRI scanLaboratory investigation, CT and MRI scan Management:Management:

Dressing of external woundsDressing of external wounds Closure of open woundsClosure of open wounds Reposition and immobilization of the fracturesReposition and immobilization of the fractures Repair of the dura matterRepair of the dura matter Antibacterial prophylaxis (as part of the general management (Eljamal, Antibacterial prophylaxis (as part of the general management (Eljamal,

1993)1993)

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Control of painControl of pain Displaced fracture may cause severe pain but strong Displaced fracture may cause severe pain but strong

analgesic ( Morphine and its derivatives) must be analgesic ( Morphine and its derivatives) must be avoided as they depress cough reflex, constrict pupils as avoided as they depress cough reflex, constrict pupils as

they may mask the signs of increasing intracranial they may mask the signs of increasing intracranial pressurepressure

Management:Management:

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

☞☞ Reduction of fractureReduction of fracture

☞☞ sedationsedation

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In patient careIn patient care Necessary medicationsNecessary medications

Diet (fluid, semi-fluid and solid food) intake and Diet (fluid, semi-fluid and solid food) intake and output (fluid balance chart)output (fluid balance chart)

Hygiene and physiotherapy Hygiene and physiotherapy

Proper timing for surgical interventionProper timing for surgical intervention

PathophysiologyPathophysiology Maxillofacial fractures result from either blunt Maxillofacial fractures result from either blunt

or penetrating trauma.or penetrating trauma. Penetrating injuries are more common in city Penetrating injuries are more common in city

hospitals.hospitals. Midfacial and zygomatic injuries.Midfacial and zygomatic injuries.

Blunt injuries are more frequently seen in Blunt injuries are more frequently seen in community hospitals.community hospitals. Nose and mandibular injuries. Nose and mandibular injuries.

PathophysiologyPathophysiology High Impact:High Impact:

Supraorbital rim – 200 GSupraorbital rim – 200 G Symphysis of the Mandible –100 GSymphysis of the Mandible –100 G Frontal – 100 GFrontal – 100 G Angle of the mandible – 70 GAngle of the mandible – 70 G

Low Impact:Low Impact: Zygoma – 50 GZygoma – 50 G Nasal bone – 30 GNasal bone – 30 G

EtiologyEtiology @60% of patients with severe facial trauma @60% of patients with severe facial trauma

have multisystem trauma and the potential for have multisystem trauma and the potential for airway compromise.airway compromise. 20-50% concurrent brain injury.20-50% concurrent brain injury. 1-4% cervical spine injuries.1-4% cervical spine injuries. Blindness occurs in 0.5-3% Blindness occurs in 0.5-3%

EtiologyEtiology 25% of women with facial trauma are victims 25% of women with facial trauma are victims

of domestic violence.of domestic violence. Increases to 30% if an orbital wall fx is present.Increases to 30% if an orbital wall fx is present.

25% of patients with severe facial trauma will 25% of patients with severe facial trauma will develop Post Traumatic Stress Disorder develop Post Traumatic Stress Disorder

AnatomyAnatomy

Emergency ManagementEmergency ManagementAirway ControlAirway Control

Control airway:Control airway: Chin lift.Chin lift. Jaw thrust.Jaw thrust. Oropharyngeal suctioning.Oropharyngeal suctioning. Manually move the tongue forward.Manually move the tongue forward. Maintain cervical immobilizationMaintain cervical immobilization

Emergency ManagementEmergency ManagementIntubation ConsiderationsIntubation Considerations

Avoid nasotracheal intubation:Avoid nasotracheal intubation: Nasocranial intubationNasocranial intubation Nasal hemorrhageNasal hemorrhage

Avoid Rapid Sequence Intubation:Avoid Rapid Sequence Intubation: Failure to intubate or ventilate.Failure to intubate or ventilate.

Consider an awake intubation.Consider an awake intubation. Sedate with benzodiazepines. Sedate with benzodiazepines.

Emergency ManagementEmergency ManagementIntubation ConsiderationsIntubation Considerations

Consider fiberoptic intubation if available. Consider fiberoptic intubation if available. Alternatives include percutaneous Alternatives include percutaneous

transtracheal ventilation and retrograde transtracheal ventilation and retrograde intubation.intubation.

Be prepared for cricothyroidotomy.Be prepared for cricothyroidotomy.

Emergency ManagementEmergency ManagementHemorrhage ControlHemorrhage Control

Maxillofacial bleeding:Maxillofacial bleeding: Direct pressure.Direct pressure. Avoid blind clamping in wounds.Avoid blind clamping in wounds.

Nasal bleeding:Nasal bleeding: Direct pressure.Direct pressure. Anterior and posterior packing.Anterior and posterior packing.

Pharyngeal bleeding:Pharyngeal bleeding: Packing of the pharynx around ET tube.Packing of the pharynx around ET tube.

HistoryHistory Obtain a history from the patient, witnesses Obtain a history from the patient, witnesses

and or EMS.and or EMS. AMPLE historyAMPLE history Specific Questions:Specific Questions:

Was there LOC? If so, how long?Was there LOC? If so, how long? How is your vision?How is your vision? Hearing problems?Hearing problems?

HistoryHistory Specific Questions:Specific Questions:

Is there pain with eye movement?Is there pain with eye movement? Are there areas of numbness or tingling on your Are there areas of numbness or tingling on your

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

Physical ExaminationPhysical Examination Inspection of the face for asymmetry.Inspection of the face for asymmetry. Inspect open wounds for foreign bodies.Inspect open wounds for foreign bodies. Palpate the entire face.Palpate the entire face.

Supraorbital and Infraorbital rimSupraorbital and Infraorbital rim Zygomatic-frontal sutureZygomatic-frontal suture Zygomatic archesZygomatic arches

Physical ExaminationPhysical Examination Inspect the nose for asymmetry, telecanthus, Inspect the nose for asymmetry, telecanthus,

widening of the nasal bridge.widening of the nasal bridge. Inspect nasal septum for septal hematoma, CSF or Inspect nasal septum for septal hematoma, CSF or

blood.blood. Palpate nose for crepitus, deformity and subcutaneous Palpate nose for crepitus, deformity and subcutaneous

air.air. Palpate the zygoma along its arch and its articulations Palpate the zygoma along its arch and its articulations

with the maxilla, frontal and temporal bone. with the maxilla, frontal and temporal bone.

Physical ExaminationPhysical Examination Check facial stability.Check facial stability. Inspect the teeth for malocclusions, bleeding and Inspect the teeth for malocclusions, bleeding and

step-off.step-off. Intraoral examination: Intraoral examination:

Manipulation of each tooth.Manipulation of each tooth. Check for lacerations.Check for lacerations. Stress the mandible.Stress the mandible. Tongue blade test.Tongue blade test.

Palpate the mandible for tenderness, swelling and Palpate the mandible for tenderness, swelling and step-off.step-off.

Physical ExaminationPhysical Examination Check visual acuity.Check visual acuity. Check pupils for roundness and reactivity.Check pupils for roundness and reactivity. Examine the eyelids for lacerations.Examine the eyelids for lacerations. Test extra ocular muscles.Test extra ocular muscles. Palpate around the entire orbits..Palpate around the entire orbits..

Physical ExaminationPhysical Examination Examine the cornea for abrasions and Examine the cornea for abrasions and

lacerations.lacerations. Examine the anterior chamber for blood or Examine the anterior chamber for blood or

hyphema.hyphema. Perform fundoscopic exam and examine the Perform fundoscopic exam and examine the

posterior chamber and the retina.posterior chamber and the retina.

Physical ExaminationPhysical Examination Examine and palpate the exterior ears.Examine and palpate the exterior ears. Examine the ear canals.Examine the ear canals. Check nuero distributions of the supraorbital, Check nuero distributions of the supraorbital,

infraorbital, inferior alveolar and mental infraorbital, inferior alveolar and mental nerves.nerves.

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesPathophysiologyPathophysiology

Results from a direct blow to the frontal bone Results from a direct blow to the frontal bone with blunt object.with blunt object.

Associated with:Associated with: Intracranial injuriesIntracranial injuries Injuries to the orbital roofInjuries to the orbital roof Dural tearsDural tears

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesClinical FindingsClinical Findings

Disruption or crepitance Disruption or crepitance orbital rimorbital rim

Subcutaneous Subcutaneous emphysemaemphysema

Associated with a Associated with a lacerationlaceration

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesDiagnosisDiagnosis

Radiographs:Radiographs: Facial views should Facial views should

include Waters, Caldwell include Waters, Caldwell and lateral projections.and lateral projections.

Caldwell view best Caldwell view best evaluates the anterior evaluates the anterior wall fractures.wall fractures.

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesDiagnosisDiagnosis

CT Head with bone CT Head with bone windows:windows: Frontal sinus fractures. Frontal sinus fractures. Orbital rim and Orbital rim and

nasoethmoidal fractures.nasoethmoidal fractures. R/O brain injuries or R/O brain injuries or

intracranial bleeds.intracranial bleeds.

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesTreatmentTreatment

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

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

Frontal Sinus/ Bone FracturesFrontal Sinus/ Bone FracturesComplicationsComplications

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

Naso-Ethmoidal-Orbital Naso-Ethmoidal-Orbital FractureFracture

Fractures that extend into Fractures that extend into the nose through the the nose through the ethmoid bones.ethmoid bones.

Associated with lacrimal Associated with lacrimal disruption and dural tears.disruption and dural tears.

Suspect if there is trauma to Suspect if there is trauma to the nose or medial orbit.the nose or medial orbit.

Patients complain of pain on Patients complain of pain on eye movement.eye movement.


Clinical findings:Clinical findings: Flattened nasal bridge or a saddle-shaped Flattened nasal bridge or a saddle-shaped

deformity of the nose.deformity of the nose. Widening of the nasal bridge (telecanthus)Widening of the nasal bridge (telecanthus) CSF rhinorrhea or epistaxis.CSF rhinorrhea or epistaxis. Tenderness, crepitus, and mobility of the nasal Tenderness, crepitus, and mobility of the nasal

complex.complex. Intranasal palpation reveals movement of the Intranasal palpation reveals movement of the

medial canthus.medial canthus.


Imaging studies:Imaging studies: Plain radiographs are insensitive.Plain radiographs are insensitive. CT of the face with coronal cuts through the CT of the face with coronal cuts through the

medial orbits.medial orbits. Treatment:Treatment:

Maxillofacial consultation.Maxillofacial consultation. ? Antibiotic? Antibiotic

Nasal FracturesNasal Fractures Most common of all facial fractures.Most common of all facial fractures. Injuries may occur to other surrounding bony Injuries may occur to other surrounding bony

structures.structures. 3 types:3 types:

DepressedDepressed Laterally displacedLaterally displaced NondisplacedNondisplaced

Nasal FracturesNasal Fractures Ask the patient:Ask the patient:

““Have you ever broken your nose before?”Have you ever broken your nose before?” ““How does your nose look to you?”How does your nose look to you?” ““Are you having trouble breathing?” Are you having trouble breathing?”

Nasal FracturesNasal Fractures Clinical findings:Clinical findings:

Nasal deformityNasal deformity Edema and tendernessEdema and tenderness EpistaxisEpistaxis Crepitus and mobilityCrepitus and mobility

Nasal FracturesNasal Fractures Diagnosis:Diagnosis:

History and physical History and physical exam.exam.

Lateral or Waters view Lateral or Waters view to confirm your to confirm your diagnosis.diagnosis.

Nasal FracturesNasal Fractures Treatment:Treatment:

Control epistaxis.Control epistaxis. Drain septal hematomas.Drain septal hematomas. Refer patients to ENT as Refer patients to ENT as

outpatient.outpatient.

Orbital Blowout FracturesOrbital Blowout Fractures Blow out fractures are the most common.Blow out fractures are the most common. Occur when the the globe sustains a direct Occur when the the globe sustains a direct

blunt forceblunt force 2 mechanisms of injury:2 mechanisms of injury:

Blunt trauma to the globeBlunt trauma to the globe Direct blow to the infraorbital rimDirect blow to the infraorbital rim

Orbital Blowout FracturesOrbital Blowout FracturesClinical FindingsClinical Findings

Periorbital tenderness, Periorbital tenderness, swelling, ecchymosis.swelling, ecchymosis.

Enopthalmus or sunken Enopthalmus or sunken eyes.eyes.

Impaired ocular Impaired ocular motility.motility.

Infraorbital anesthesia.Infraorbital anesthesia. Step off deformityStep off deformity

Orbital Blowout FracturesOrbital Blowout FracturesImaging studiesImaging studies

Radiographs:Radiographs: Hanging tear drop signHanging tear drop sign Open bomb bay doorOpen bomb bay door Air fluid levelsAir fluid levels Orbital emphysemaOrbital emphysema

Orbital Blowout FracturesOrbital Blowout FracturesImaging studiesImaging studies

CT of orbitsCT of orbits Details the orbital Details the orbital

fracturefracture Excludes retrobulbar Excludes retrobulbar

hemorrhage.hemorrhage. CT HeadCT Head

R/o intracranial injuries R/o intracranial injuries

Orbital Blowout FracturesOrbital Blowout FracturesTreatmentTreatment

Blow out fractures without eye injury do not require Blow out fractures without eye injury do not require admissionadmission Maxillofacial and ophthalmology consultationMaxillofacial and ophthalmology consultation TetanusTetanus Decongestants for 3 daysDecongestants for 3 days Prophylactic antibioticsProphylactic antibiotics Avoid valsalva or nose blowing Avoid valsalva or nose blowing

Patients with serious eye injuries should be admitted Patients with serious eye injuries should be admitted to ophthalmology service for further care.to ophthalmology service for further care.

Zygoma FracturesZygoma Fractures The zygoma has 2 major components:The zygoma has 2 major components:

Zygomatic archZygomatic arch Zygomatic bodyZygomatic body

Blunt trauma most common cause.Blunt trauma most common cause. Two types of fractures can occur:Two types of fractures can occur:

Arch fracture (most common)Arch fracture (most common) Tripod fracture (most serious)Tripod fracture (most serious)

Zygoma Arch FracturesZygoma Arch Fractures Can fracture 2 to 3 places along the archCan fracture 2 to 3 places along the arch

Lateral to each end of the archLateral to each end of the arch Fracture in the middle of the archFracture in the middle of the arch

Patients usually present with pain on opening Patients usually present with pain on opening their mouth.their mouth.

Zygoma Arch FracturesZygoma Arch FracturesClinical FindingsClinical Findings

Palpable bony defect Palpable bony defect over the archover the arch

Depressed cheek with Depressed cheek with tendernesstenderness

Pain in cheek and jaw Pain in cheek and jaw movementmovement

Limited mandibular Limited mandibular movementmovement

Zygoma Arch FracturesZygoma Arch FracturesImaging Studies & TreatmentImaging Studies & Treatment

Radiographic imaging:Radiographic imaging: Submental view (bucket Submental view (bucket

handle view)handle view) Treatment:Treatment:

Consult maxillofacial Consult maxillofacial surgeonsurgeon

Ice and analgesiaIce and analgesia Possible open elevationPossible open elevation

Zygoma Tripod FracturesZygoma Tripod Fractures Tripod fractures consist Tripod fractures consist

of fractures through:of fractures through: Zygomatic archZygomatic arch Zygomaticofrontal Zygomaticofrontal

suturesuture Inferior orbital rim and Inferior orbital rim and

floorfloor

Zygoma Tripod FracturesZygoma Tripod FracturesClinical FeaturesClinical Features

Clinical features:Clinical features: Periorbital edema and Periorbital edema and

ecchymosisecchymosis Hypesthesia of the Hypesthesia of the

infraorbital nerveinfraorbital nerve Palpation may reveal Palpation may reveal

step offstep off Concomitant globe Concomitant globe

injuries are commoninjuries are common

Zygoma Tripod FracturesZygoma Tripod FracturesImaging StudiesImaging Studies

Radiographic imaging:Radiographic imaging: Waters, Submental and Waters, Submental and

Caldwell viewsCaldwell views Coronal CT of the facial Coronal CT of the facial

bones:bones: 3-D reconstruction3-D reconstruction

Zygoma Tripod FracturesZygoma Tripod FracturesTreatmentTreatment

Nondisplaced fractures without eye involvementNondisplaced fractures without eye involvement Ice and analgesicsIce and analgesics Delayed operative consideration 5-7 daysDelayed operative consideration 5-7 days Decongestants Decongestants Broad spectrum antibiotics Broad spectrum antibiotics TetanusTetanus

Displaced tripod fractures usually require admission Displaced tripod fractures usually require admission for open reduction and internal fixation.for open reduction and internal fixation.

Maxillary FracturesMaxillary Fractures High energy injuries.High energy injuries. Impact 100 times the force of gravity is Impact 100 times the force of gravity is

required .required . Patients often have significant multisystem Patients often have significant multisystem

trauma.trauma. Classified as LeFort fractures.Classified as LeFort fractures.

Maxillary FracturesMaxillary FracturesLeFort ILeFort I

Definition:Definition: Horizontal fracture of Horizontal fracture of

the maxilla at the level the maxilla at the level of the nasal fossa.of the nasal fossa.

Allows motion of the Allows motion of the maxilla while the nasal maxilla while the nasal bridge remains stable.bridge remains stable.


Clinical findings:Clinical findings: Facial edemaFacial edema Malocclusion of the Malocclusion of the

teethteeth Motion of the maxilla Motion of the maxilla

while the nasal bridge while the nasal bridge remains stableremains stable


Radiographic findings:Radiographic findings: Fracture line which Fracture line which

involvesinvolves Nasal apertureNasal aperture Inferior maxillaInferior maxilla Lateral wall of maxillaLateral wall of maxilla

CT of the face and head CT of the face and head coronal cutscoronal cuts 3-D reconstruction3-D reconstruction

Maxillary FracturesMaxillary FracturesLeFort IILeFort II

Definition:Definition: Pyramidal fracturePyramidal fracture

MaxillaMaxilla Nasal bones Nasal bones Medial aspect of the Medial aspect of the

orbitsorbits


Clinical findings:Clinical findings: Marked facial edemaMarked facial edema Nasal flatteningNasal flattening Traumatic telecanthusTraumatic telecanthus Epistaxis or CSF Epistaxis or CSF

rhinorrhea rhinorrhea Movement of the upper Movement of the upper

jaw and the nose. jaw and the nose.


Radiographic imaging:Radiographic imaging: Fracture involves:Fracture involves:

Nasal bonesNasal bones Medial orbitMedial orbit Maxillary sinusMaxillary sinus Frontal process of the Frontal process of the

maxilla maxilla CT of the face and headCT of the face and head

Maxillary FracturesMaxillary FracturesLeFort IIILeFort III

Definition:Definition: Fractures through:Fractures through:

MaxillaMaxilla ZygomaZygoma Nasal bonesNasal bones Ethmoid bonesEthmoid bones Base of the skullBase of the skull


Clinical findings:Clinical findings: Dish faced deformityDish faced deformity Epistaxis and CSF Epistaxis and CSF

rhinorrhea rhinorrhea Motion of the maxilla, Motion of the maxilla,

nasal bones and zygomanasal bones and zygoma Severe airway Severe airway

obstructionobstruction


Radiographic imaging:Radiographic imaging: Fractures through:Fractures through:

Zygomaticfrontal sutureZygomaticfrontal suture ZygomaZygoma Medial orbital wallMedial orbital wall Nasal boneNasal bone

CT Face and the HeadCT Face and the Head

Maxillary FracturesMaxillary FracturesTreatmentTreatment

Secure and airwaySecure and airway Control BleedingControl Bleeding Head elevation 40-60 degreesHead elevation 40-60 degrees Consult with maxillofacial surgeonConsult with maxillofacial surgeon Consider antibioticsConsider antibiotics AdmissionAdmission

Mandible FracturesMandible FracturesPathophysiologyPathophysiology

Mandibular fractures are the Mandibular fractures are the third most common facial third most common facial fracture.fracture.

Assaults and falls on the Assaults and falls on the chin account for most of the chin account for most of the injuries.injuries.

Multiple fractures are seen Multiple fractures are seen in greater then 50%.in greater then 50%.

Associated C-spine injuries Associated C-spine injuries – 0.2-6%.– 0.2-6%.

Mandible FracturesMandible FracturesClinical findingsClinical findings

Mandibular pain.Mandibular pain. Malocclusion of the teethMalocclusion of the teeth Separation of teeth with Separation of teeth with

intraoral bleedingintraoral bleeding Inability to fully open Inability to fully open

mouth.mouth. Preauricular pain with Preauricular pain with

biting. biting. Positive tongue blade test.Positive tongue blade test.

Mandible FracturesMandible Fractures Radiographs:Radiographs:

Panoramic viewPanoramic view Plain view: PA, Lateral and a Townes viewPlain view: PA, Lateral and a Townes view

Mandibular FracturesMandibular FracturesTreatmentTreatment

Nondisplaced fractures:Nondisplaced fractures: AnalgesicsAnalgesics Soft dietSoft diet oral surgery referral in 1-2 daysoral surgery referral in 1-2 days

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

All fractures should be treated with antibiotics and All fractures should be treated with antibiotics and tetanus prophylaxis.tetanus prophylaxis.

Mandibular DislocationMandibular Dislocation Causes of mandibular dislocation are:Causes of mandibular dislocation are:

Blunt traumaBlunt trauma Excessive mouth openingExcessive mouth opening

Risk factors:Risk factors: Weakness of the temporal mandibular ligamentWeakness of the temporal mandibular ligament Over stretched joint capsule Over stretched joint capsule Shallow articular eminenceShallow articular eminence Neurologic diseasesNeurologic diseases

Mandibular DislocationMandibular Dislocation The mandible can be The mandible can be

dislocated:dislocated: Anterior 70%Anterior 70% PosteriorPosterior LateralLateral Superior Superior

Dislocations are mostly Dislocations are mostly bilateral.bilateral.

Mandibular DislocationMandibular Dislocation Posterior dislocations:Posterior dislocations:

Direct blow to the chinDirect blow to the chin Condylar head is pushed against the mastoidCondylar head is pushed against the mastoid

Lateral dislocations:Lateral dislocations: Associated with a jaw fractureAssociated with a jaw fracture Condylar head is forced laterally and superiorlyCondylar head is forced laterally and superiorly

Superior dislocations:Superior dislocations: Blow to a partially open mouthBlow to a partially open mouth Condylar head is force upward Condylar head is force upward

Mandibular DislocationMandibular Dislocation Clinical features:Clinical features:

Inability to close mouthInability to close mouth PainPain Facial swellingFacial swelling

Physical exam:Physical exam: Palpable depressionPalpable depression Jaw will deviate awayJaw will deviate away Jaw displaced anteriorJaw displaced anterior

Mandibular DislocationMandibular Dislocation Diagnosis:Diagnosis:

History & Physical examHistory & Physical exam X-raysX-rays CT CT

Mandibular DislocationMandibular Dislocation Treatment:Treatment:

Muscle relaxantMuscle relaxant AnalgesicAnalgesic Closed reduction in the Closed reduction in the

emergency roomemergency room

Mandibular DislocationMandibular Dislocation Treatment:Treatment:

Oral surgeon consultation:Oral surgeon consultation: Open dislocationsOpen dislocations Superior, posterior or lateral dislocationsSuperior, posterior or lateral dislocations Non-reducible dislocationsNon-reducible dislocations Dislocations associated with fracturesDislocations associated with fractures

Mandibular DislocationMandibular Dislocation Disposition:Disposition:

Avoid excessive mouth openingAvoid excessive mouth opening Soft dietSoft diet AnalgesicsAnalgesics Oral surgery follow up Oral surgery follow up

Maxillofacial trauma

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