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Maxillofacial Trauma Tintinalli’s Chapter 257

Maxillofacial Trauma Tintinalli’s Chapter 257. Anatomy. Sutures of the face cause predictable fracture patterns LeFort Fractures & “blowout fractures”. Initial Management. Airway, Airway, Airway Jaw Thrust & Naso/oropharyngeal airways C spine

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Maxillofacial Trauma Tintinalli’s Chapter 257

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  1. Maxillofacial Trauma Tintinalli’s Chapter 257

  2. Anatomy • Sutures of the face cause predictable fracture patterns • LeFort Fractures & “blowout fractures”

  3. Initial Management • Airway, Airway, Airway • Jaw Thrust & Naso/oropharyngeal airways • C spine • Excessive Bleeding = Intubation vs. Surgical Airway • Be ready for a cricothyroidotomy or jet insufflation

  4. Initial Management • Bleeding • Direct pressure usually does the job • Gross deformities may require a quick manual reduction • If oral, intubate and pack the oro/nasopharynx

  5. After initial ABCs • History • Mechanism • Helps to focus examination • Half of all abused women/children are injured in the head/face/mouth/neck. • Three simple questions for assessment • How is your vision? • Monocular disturbance = eyeball/retina • Binocular disturbance = muscles/nerves/brain • Is any part of your face numb? • Are your teeth meeting normally?

  6. Physical Exam • Inspection • Look for asymmetry • Elongated face – LeFort’s fractures • Bells Palsy – Temporal bone fractures • Battles Sign & Raccoon’s Eyes

  7. Physical Exam

  8. Physical Exam • Palpation • Tenderness, crepitus, subcutaneous air • Close attention to more vulnerable structures • Grab and rock the hard pallet • Check for anesthesia • Infraorbital nerve = upper lip, lower lid, maxillary teeth • Mandibular fractures = lower lip, mandibular teeth

  9. Eye Examination • Visual acuity if able • Pupil reactivity, alignment, shape • Extraocular Muscles • Slit Lamp • Swinging-flashlight Test “Marcus Gunn Pupil” • Medial Canthi Distance (normal 35-40mm)

  10. Nose • Look for asymmetry • Needs to be set in 3-7 days • Two things to rule out • Septal hematoma • CSF rhinorrhea

  11. Ears • Asymmetry, Ecchymosis, Drainage • TM Rupture • Subperichondrial Hematoma • I & D plus compression dressing

  12. Oral & Mandibular • Sensation, Deformity, Malocclusion • Tongue Blade Test • Intraoral Palpation

  13. Imaging Tests • CT vs. Plain X ray • Get the CT if significant trauma • Plain X ray Views • Waters -evaluates continuity of orbital rims, provides an initial diagnosis of blowout fractures, and will demonstrate air/fluid levels in the maxillary sinus • Caldwell -best details the bones of the upper face, confirms ethmoidal and frontal sinus fractures, as well as lateral orbital injuries • Submental/Vertex or “Jug Handle” - the base of the skull and the zygomatic arches • Towne View - useful for evaluating the mandibular ramus and condyles, as well as the base of the skull

  14. Waters Submental Caldwell Townes Imaging tests

  15. Special Fractures • Frontal Sinus / Frontal Bone • Direct Blow mech • Associated with intracranial trauma • Treatment: • Usually 1st Gen. Ceph., Augmentin, Bactrim • Complications: • Cranial empyema • Posterior wall or depressed fractures require IV antibiotics and Neuro/ENT consultation

  16. Special Fractures • Nasoethmoidal Injuries • Usually blunt trauma • Telecanthus (increase medial canthal distance); epiphora (tears overflowing the lower lid); pain on eye movement • Should warrant a consultation or at least a CT

  17. Special Fractures • Orbital • Blowout Fractures • Enophtalmos or sunken globe • Infraorbital Anesthesia • Diplopia - especially on upward gaze (Inf. Rectus m.) • Step off deformity or Sub Q Air • Treatment: CT for further evaluation; antibiotics for sinus pathogens; treatment may be delayed for 1-2 weeks; large amount of sub Q air and pain warrants intraocular pressures & if increased - cantholysis

  18. Special Fractures • Zygomatic Fractures • Arch – pain mange and home • Tripod - involves the infraorbital rim, a diastasis of the zygomaticofrontal suture, and disruption of the zygomaticotemporal junction at the arch; usually require inpatient management with consultation

  19. Special Fractures • Maxillary Fractures • High energy mech; a patient may have malocclusion, an open bite, facial lengthening, CSF rhinorrhea, or periorbital ecchymosis • LeFort Classification used, but usually you see a mixture instead of each isolated subtype • Type I - transverse fracture separates the body of the maxilla from the lower portion of the pterygoid plate and nasal septum • Type II – defined by a pyramidal fracture of the central maxilla and the palate • Type III - also called craniofacial disjunction, fracture extends through the frontozygomatic suture lines, across the orbit, and through the base of the nose and ethmoid region. • Type IV - involves the frontal bone as well as the midface

  20. LeFort Fractures

  21. Special Fractures • Mandibular Fractures • 2nd most common facial fracture • Body then angle then condyle in order of injury • Malocclusion and tongue blade test are sensitive indicators of fracture • Intraoral lacerations (open fx), sublingual ecchymosis; lower lip/dentation anesthesia PE findings indicating fracture • Open fractures may need admission with IV Pen G or Clindamycin

  22. Mandibular Fractures

  23. Reference • Tintinalli Chapter 257

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