Maxillofacial Trauma Joe Lex, MD, FACEP, FAAEM Temple University School of Medicine

Transcription

Maxillofacial Trauma Joe Lex, MD, FACEP, FAAEM Temple University School of Medicine
Maxillofacial Trauma
Joe Lex, MD, FACEP, FAAEM
Temple University School of Medicine
Philadelphia, PA USA
Joseph.Lex@TUHS.Temple.edu
Lecture Outline
• Emergency management
• Facial exam
• Fractures
– Major
– Minor
• Soft tissue injuries
• Unusual injuries
Causes of Mortality
• Acute
– Airway compromise
– Exsanguination
– Associated intracranial or cervicalspine injury
• Delayed
– Meningitis
– Oropharyngeal infections
Epidemiology
• Estimated 3,000,000 facial trauma
cases per year in USA
• Estimated 40 to 50% of motor
vehicle victims have facial injury
• No uniform reporting or registry of
cases
Functions of Face
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Respiratory  upper airway
Visual
Olfactory
Mastication
Cosmetic
Communication
Individual recognition
Management Sequence
• Airway control / immobilize cervical
spine
• Bleeding control
• Complete the primary survey
• Secondary survey
– Consider NG or OG tube placement
Management Sequence
• Plain radiographs if fractures
suspected
• CT if suspect complex fractures
Management Sequence
• Repair soft tissue immediately if no
other injuries
• Delay soft tissue repair until patient
in OR if surgery for other injuries
necessary
Initial Management
Step 1: Airway control
• Oxygen for all patients
• May need to keep patient sitting or
prone
• Stabilize C-spine early
• Large bore (Yankauer) suction
available
Initial Management
Step 1: Airway control
• Orotracheal intubation preferred
over nasotracheal if possible
midfacial fracture and invasive
airway needed
• Combitube®, retrograde wire, or
cricothyroidostomy if unable to
orotracheally intubate
Initial Management
Step 2 : Bleeding control
• Can be major threat to life
• Use universal precautions
• Direct pressure dressings initially
• Contraindicated: blind vessel
clamping
Initial Management
Step 2 : Bleeding control
• Rapid nasal packing may be
necessary
– Be sure blood is not just running
down posterior pharynx
Initial Management
Step 2 : Bleeding control
• Rarely: emergent cutdown and
ligation of external carotid artery
needed to prevent exsanguination
• Note: Although shock in facial
trauma patient is usually due to
other injuries, it is possible to bleed
to death from a facial injury
Airway Compromise
• Blood in airway
• “Debris” in airway
– Vomitus, avulsed tissue, teeth or
dentures, foreign bodies
• Pharyngeal or retropharyngeal
tissue swelling
• Posterior tongue displacement from
mandible fractures
Secondary Survey
Scalp
• Check for lacerations, hematomas,
stepoffs, tenderness
• Bleeding maybe brisk until sutured
• Can use stapler for rapid closure
Secondary Survey
Ears
• Examine pinnae, canal walls,
tympanic membranes
• Suction gently under direct vision if
blood in canal
• Put drop of canal fluid on filter
paper for “ring sign”  CSF leak
• Assess hearing
Secondary Survey
Eyes
• Pupils, anterior chamber, fundi,
extraocular movements
• Conjunctivae for foreign bodies
• Palpate orbital rims
– No globe palpation if suspect
penetration
Secondary Survey
Eyes
• Lid injury can leave cornea
exposed
– Use artificial tears or cellulose gel
Secondary Survey
Overall facial appearance
• Assess for symmetry, deformity,
discoloration, nasal alignment
• Palpate forehead & malar areas
Secondary Survey
Nose
• Check septum for hematoma &
position
• Check airflow in both nares
• Palpate nasal bridge for crepitus
• Check fluid on filter paper for “ring
sign” (for CSF leak)
Secondary Survey
Mouth
• Check occlusion
• Reflect upper & lower lips
• Check Stenson's duct for blood
• Palpate along mandibular and
maxillary teeth (be careful !)
Secondary Survey
Mouth
• Palpate along exterior of mandible
• Pull forward on maxillary teeth
Secondary Survey
Neurologic
• Skin fold symmetry at rest
• Motor: each division of CN-VII
• Sensation: 3 divisions of CN-V
• Sensation on tongue
• Gag reflex
Fracture Classification
Major
• Lefort I, II, III
• Mandibular
Minor
• Nasal
• Sinus wall
• Zygomatic
• Orbital floor
• Antral wall
• Alveolar ridge
Forces Required
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Nasal fracture  30 g
Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
Lefort Fractures
• Lefort fractures can coexist with
additional facial fractures
• Patient may have different Lefort
type fracture on each side of the
face
Differentiating Leforts
Pull forward on maxillary teeth
• Lefort I: maxilla only moves
• Lefort II: maxilla & base of nose
move:
• Lefort III: whole face moves:
Lefort I: Nasomaxillary
• Horizontal fracture extending
through maxilla between maxillary
sinus floor & orbital floor
– Crepitus over maxilla
– Ecchymosis in buccal vestibule
– Epistaxis: can be bilateral
– Malocclusion
– Maxilla mobility
Lefort I: Nasomaxillary
• Closed reduction
• Intermaxillary fixation: secures
maxilla to mandible
• May need wiring or plating of
maxillary wall and / or zygomatic
arch
• Antibiotics: anti-staphylococcal
Lefort II: Pyramidal
• Subzygomatic midfacial fracture
with a pyramid-shaped fragment
separated from cranium and lateral
aspects of face
Lefort II: Pyramidal
Signs & symptoms
• Midface crepitus
• Face lengthening
• Malocclusion
• Bilateral epistaxis
• Infraorbital paresthesia
• Ecchymoses: buccal vestibule,
periorbital, subconjunctival
Lefort II: Pyramidal
• Hemorrhage or airway obstruction
may require emergent surgery
• Treatment can often be delayed till
edema decreased
Lefort II: Pyramidal
Usually require
• Intermaxillary fixation
• Interosseous wiring or plating of
infraorbital rims, nasal-frontal area,
& lateral maxillary walls
• May need additional suspension
wires
• Antibiotics
Lefort III
• Craniofacial dissociation
• Bilateral suprazygomatic fracture
resulting in a floating fragment of
mid-facial bones, which are totally
separated from the cranial base
Lefort III
Signs and Symptoms
• Face lengthening: “caved-in” or
“donkey face”
• Malocclusion: “open bite”
• Lateral orbital rim defect
• Ecchymoses: periorbital,
subconjunctival
Lefort III
Signs and Symptoms
• Bilateral epistaxis
• Infraorbital paresthesia
• Often medial canthal deformity
• Often unequal pupil height
Lefort III
• Usually associated with major soft
tissue injury requiring emergent
surgery for bleeding control
• Surgery can be delayed till edema
resolves
• Intermaxillary fixation
Lefort III
• Transosseous wiring or plating
– Frontozygomatic suture
– Nasofrontal suture
– May need extracranial fixation if
concurrent mandibular fracture
• Antibiotics
Forces Required
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Nasal fracture  30 g
Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
Mandible Fractures
• Airway obstruction from loss of
attachment at base of tongue
• >50 % are multiple
• Condylar fractures associated with
ear canal lacerations & high
cervical fractures
• High infection potential if any
violation of oral mucosa
Mandible Fractures
Signs and symptoms
• Malocclusion
• Decreased jaw range of motion
• Trismus
• Chin numbness
• Ecchymosis in floor of mouth
• Palpable step deformity
Mandible Fractures
• Tongue blade test: have patient bite
down while you twist. If no fracture,
you will be able to break the blade.
Mandible Fractures
Treatment
• Prompt fixation: intermaxillary
fixation (arch bars), +/- body wiring
or plating
TMJ Dislocation
• Can occur from direct blow to
mandible
• Can occur “spontaneously” from
yawning or laughing
• Mandible dislocates forward &
superiorly
• Concurrent masseter & pterygoid
spasm
TMJ Dislocation
Symptoms
• Patient presents with mouth open,
cannot close mouth or talk well
• Can be misdiagnosed as
psychiatric or dystonic reaction
TMJ Dislocation
Treatment
• Manual reduction: place wrapped
thumbs on molars & push
downward, then backward
• Be careful not to get bitten
• Usually does not require procedural
sedation or muscle relaxants
Forces Required
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Nasal fracture  30 g
Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
Nasal Bone Fractures
• Often diagnosed clinically: x-ray not
needed
• Emergent reduction not necessary
except to control epistaxis
• Usually do not need antibiotics
• Early reduction under local
anesthesia useful if nares
obstructed
Nasal Bone Fractures
• Nasal septal hematoma: incise &
drain, anterior pack, antibiotics,
follow-up at 24 hours
• Follow-up timing for recheck or
reduction:
– Children: 3 to 5 days
– Adults: 7 days
Forces Required
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•
Nasal fracture  30 g
Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
Zygomatic Fractures
Tripod (tri-malar) fracture
• Depression of malar eminence
• Fractures at temporal, frontal, and
maxillary suture lines
Zygomatic Fractures
Isolated arch fracture
• Less common
• Shows best on submental-vertex xray view
• Painful mandible movement
• Usually treat with fixation wire if
arch depressed
Zygomatic Fractures
Tripod S & S
• Unilateral
epistaxis
• Depressed malar
prominence
• Subcutaneous
emphysema
• Orbital rim stepoff
• Altered relative
pupil position
• Periorbital
ecchymosis
• Subconjunctival
hemorrhage
• Infraorbital
hypoesthesia
Forces Required
•
•
•
•
•
•
•
Nasal fracture  30 g
Zygoma fractures  50 g
Mandibular (angle) fractures  70 g
Frontal region fractures  80 g
Maxillary (midline) fractures  100 g
Mandibular (midline) fractures  100 g
Supraorbital rim fractures  200 g
Supraorbital Fractures
Frontal sinus fracture
• Often associated with intracranial
injury
• Often show depressed glabellar
area
• If posterior wall fracture, then dura
is torn
Supraorbital Fractures
Ethmoid fracture
• Blow to bridge of nose
• Often associated with cribiform
plate fracture, CSF leak
• Medial canthus ligament injury
needs transnasal wiring repair to
prevent telecanthus
Orbital Fractures
• “Blow out” fracture of floor
• Rule out globe injury
– Visual acuity
– Visual fields
– Extraocular movement
– Anterior chamber
– Fundus
– Fluorescein & slit lamp
Orbital Fractures
Symptoms and signs
• Diplopia: double vision
• Enophthalmos: sunken eyeball
• Impaired EOM’s
• Infraorbital hypesthesia
• Maxillary sinus opacification
• “Hanging drop” in maxillary sinus
Orbital Fractures
• Diplopia with upward gaze: 90%
– Suggests inferior blowout
– Entrapment of inferior rectus &
inferior oblique
• Diplopia with lateral gaze: 10%
– Suggests medial fracture
– Restriction of medial rectus muscle
Orbital Fracture: Treatment
• Sometimes extraocular muscle
dysfunction can be due to edema
and will correct without surgery
• Persistent or high grade muscle
entrapment requires surgical repair
of orbital floor (bone grafts, Teflon,
plating, etc.)
Facial Soft Tissue Injuries
• Before repair, rule out injury to:
– Facial nerve
– Trigeminal nerve
– Parotid duct
– Lacrimal duct
– Medial canthal ligament
• Remove embedded foreign
material to prevent tattooing
Facial Soft Tissue Rules
• For lip lacerations, place first suture
at vermillion border
• Never shave an eyebrow: may not
grow back
• If debridement of eyebrow
laceration needed, debride parallel
to angle of hairs rather than
vertically
Facial Soft Tissue Rules
• Antibiotics for 3 to 5 days for any
intraoral laceration (penicillin VK or
erythromycin) and if any exposed
ear cartilage (anti-staphylococcal
antibiotic) – no evidence
• Remove sutures in 3 to 5 days to
prevent cross-marks
Facial Soft Tissue Rules
• Most face bite wounds can be
sutured primarily
• Clean facial wounds can be
repaired up to 24 hours after injury
• Place incisions or debridement
lines parallel to the lines of least
skin tension (Lines of Langer)
Questions??
Summary
• Assess ABC's first
• Do complete exam as part of
secondary survey
• Obtain standard X-rays and / or CT
scan as indicated
• Decide if specialist referral and / or
operative repair indicated
Summary
• Arrange followup after repair to
assess for delayed complications or
cosmetic problems