Traffic accidents

Interpersonel violence

Sports accidents

Home accidents

Occupational accidents

Shot-gun injuries

Maintenance of airway Cleaning of blood, vomit

Aspiration of blood, saliva, and gastric contents ,FB

Secured by Early Intubation or Tracheostomy

Hemorrhage- Direct pressure n ligation of vessels

Associated injuries- asso with injuries of head,

chest, abdomen,neck,larynx,cervical spines or limbs should

b attended

Facial lacerations- wound is thoroughly cleaned of

any dirt,grease,foreign matter and closed by

approximation of each layer.

Parotid gland and duct-if exposed ,repaired by

suturing.

Facial nerve-exposed by superficial parotidectomy

and cut ends are approximated with 8-0 or10-0 silk

under magnification.

Upper third-above the level of supraorbital

ridge.

Middle third-between supraorbital ridge and

upper teeth.

Lower third-mandible and lower teeth.

FRONTAL SINUS-

Anterior wall #-depressed or communited,mainly

cosmetic.

-Sinus is approached through a wound in the skin if present

or through brow incision.Interior of the sinus is inspected

Posterior wall #-may b accompanied by dural tears, brain

injury and csf rhinorrhea.

Injury to nasofrontal duct-causes obstruction make

large communication b/w sinus and nose.

SUPRAORBITAL RIDGE-

-cause periorbital ecchymosis ,flattening of the eyebrow,

proptosis or downward displacement of eye..

-Requires open reduction through an incision in the brow

or transverse skin line of forehead.

#OF FRONTAL BONE-

-depressed/linear, with/without separation.

-Often extends into orbit.

-Assoc with brain injury and cerebral edema-

neurosurgical correction.

Nasal Bones And Septum-

TYPES-

DEPRESSED-due to frontal blow.

-causes open book fractures.

-septum is collapsed and nasal bones is splayed out.

ANGULATED-lateral blow.

-U/L depression of nasal bone on the same side or both

and septum with deviation of nasal bridge

CLINICAL FEATURES--Swelling of the nose

-Periorbital ecchymosis

-Tenderness

-Nasal deformity

-Crepitus and mobility of #ed fragments

-Epistaxis

-Nasal obstruction

-Laceration of nasal skin

DIAGNOSIS--Best made on physical examination.

-Xrays may not show #

-should include water’s view,right and left lateral views and occlusal view

TREATMENT-

-Simple #-no treatment.

-Others-closed or open reduction.edema interferes with accurate reduction so done before appearance or after subsiding(5-7 days).

Closed Reduction--# reduced by straight, blunt elevator guided by digital

manipulation from outside,

- Laterally displaced-digital pressure in opp side.

- impacted fragments - disimpaction with walsham or

asch’s forceps before realignment.

Open Reduction-when closed method fails.

Direct force over the nasion

Nasal bones, perpendicular plate of ethmoid, ethmoidal air

cells, medial orbital wall are fractured and displaced

posteriorly

Clinical features

-telecanthus

-pug nose

-periorbital ecchymoses

-orbital hematoma

-CSF leakage

-Displacement of eyeball

Diagnosis- Xray, CT scans(more usefull

Treatment-

Closed reduction-

• # is reduced with Asch’s forceps and stabilized by a wire

passed thru fractured bony fragments and septum n then tied

over the lead plates

- intranasal packing

- splinting kept for 10 days

Open reduction-

• required in cases of extensive comminution of nasal n

orbital bones and complicated by injury to lacrimal

apparatus , medial canthal ligaments frontal sinus

-H type incision

-nasal bones n orbital walls can b reduced

-medial canthal ligaments avulsed-restored with a thru

n thru wire

2nd most frequently fractured bone

Direct trauma

Zygoma is separated from its processes

Clinical features

-Flattening of malar prominence

-step deformity

-anesthesia in distri of infraorbital N

-Trismus

-Oblique palpebral fissure

-Restricted ocular movements

-periorbital emphysema

Diagnosis- Water’s view shows # n displacement best,

CT

Treatment-Only displaced # requires treatment

-open reduction n internal wire fixation – best results

- fracture is exposed at frontozygomatic suture through laterlal

brow incision n reduced by passing an elevator behind the

zygoma

-Wire fixation is done at frontozygomatic suture n infraorbital

margin(incision at lower lid)

Generally breaks into 2 fragments which get depressed

3 fracture lines- one at each end n 3rd in centre of arch

Clinical features

-depression in the area of arch

-local pain- aggravated by talking chewing

-Trismus or limitation of movements of mandible due to

impingement of fragments on the condyles or coronoid

process

Diagnosis-best seen on submentovertical view of skull

Treatment-vertical incision on hair bearing area above or infront of the

ear, cutting through temporal fascia

-an elevator passed deep to temporal fascia and carried under

the depressed bony fragments which r then reduced

- fixation not required as fragments remain stable

Axial CT scan

isolated depressed left zygomatic arch

fracture.

Accompanied with zygomatic n Le Fort II fracture

Isolated- large blunt objects, Orbital blowout fracture

Clinical Features-Ecchymosis of lid, conjuntiva,

and sclera

-Enophthalmos with inferior

displacement of the eyeball

-Diplopia

-Hypothesia or anesthesia of cheek

and upper lip( infraorbital N

A- small orbital blow-out fracture is confined to

the orbital floor

B- larger blow-out fracture extends to involve

to the lower medial orbit as well as orbital floor

Coronal CT

Diagnosis- Waters’ view shows a convex opacity bulging in to the antrum from above(tear drop opacity)

- CT confirms the diagnosis

Treatment

-Indications for surgery- enophthalmos n persistent diplopia

-by transantral approach

-Infraorbital approach alone or in combination with transantralapproach

-a pack can b kept in the antrum to support fragments

-Badly comminuted fractures can be repaired by bone graft from iliac crest, nasal septum or antr wall of antrum

-silicon and teflon sheets have also been used to reconstruct the orbital floor

1. Le Fort I(transeverse) fractures runs above and parallel to the palate

-It crosses lower part of nasal septum, maxillary antra n pterygoid plates

2. Le Fort II(pyramidal) –passes though the root of nose , lacrimal bone,floor of orbit, upper part of maxillary sinus and pterygoid plates

3. Le fort III(craniofacial dysjunction)

complete seperation of facial bones from the cranial bones. Fracture line passes through root of nose, ethmofrontaljunction,superior orbital fissure, lateral wall of orbit, frontozygmatic and temporozygomatic sutures and the upper part of pterygoid plates

Clinical features- Malocclusion of teeth with antr open bite

- Elongation of midface

- mobility in the maxilla

-CSF rhinorrhoea (cribriform plate injured in II n III)

Diagnosis-Xray- water’s view, posteroanterior view lateral view

-CT

Coronal CT

Treatment-immediate attention- to restore airway n stop haemorrhage

-fixation achieved by

a. Interdental wiring

b.Intermaxillary wiring using arch bars

c. open reduction and interosseous wiring

d. wire slings from frontal bone,zygoma or infraorbital rim to

teeth or arch bars

Classified according to

the location

CABS

Displacement of fractures

determined by

- direction of pull of muscles

attached

-direction of fracture line

-bevel of fracture

Clinical features• in # of condyles-

-if fragments not displaced- pain and trismus , tenderness

can be elicited

-if displaced- also malocclusion of teeth and deviation of jaw

to the opp side on opening the mouth

• Fractures of angle, body n symphysis – diagnosed by

intraoral n extraoral palpation

• -step deformity, malocclusion of teeth, ecchymosis of oral

mucosa, tenderness at site of fracture

Treatment-closed methods- interdental wiring and intermaxillary fixation

-open methods- fracture site is exposed and fragments fixed by

direct interosseous wiring (further strengthened by by a wire

tied in shape of 8)

-Now compression plates are available- prolonged

immobilisation n intermaxillary fixation can b avoided

-immobilisation of mandible beyond 3 weeks in condylar

fractures- ankylosis of TMJ

- therefore wires r removed n jaw exercises started

-if occlusion is still disturbing- wires r reapplied for another

week n process repeated until bite n jaw movements r

normal