#DEN4002
#D4/S2/W8
#OralSurgery

Facial Trauma

Facial trauma

• epidemiology
  • 5% paediatric, primary cause is falling
  • primary dentition 11-30%
  • permanent mixed dentition 5-20%
  • M:F 2:1
• common causes
  • children: contact sports, playground activities, child abuse
  • adult: motor vehicle collisions, contact sports, assult/intentional violence, industrial accident

• skull is like a frame
  • top area is frontal bone
  • lateral struts are lateral orbital margins and ZMC
  • lower platform is mandible
• when damaged, the frame is reconstructed first
  
  
  
  
  
  

Emergency Management

Emergency management

**Management **

• ABCDE
• airway
  • most urgent
  • mandibular fracture?
  • tongue trauma
    • intubation/surgical airway
      • cricothyroidotomy
      • tracheostomy
      • no nasotracheal intubation, tube can be displaced through middle cranial base into brain
• airway control
  • chin lift
  • jaw thrust
  • oropharyngeal suctioning
  • manually move tongue forward
  • maintain cervical immobilisation
• haemorrhage/circulation control
  • rarely develop shock from facial bleeding alone
  • direct pressure
  • fracture reduction
  • soft tissue closure
  • nasal haemorrhage may require anterior and posterior packing
    • anterior via adrenaline soaked gauze
    • posterior via folley catheter
      

Physical Exam

Inpsection

• initial patient appearance
• foreign bodies
• swelling and ecchymosis
• facial elongation
  • lefort fracture
• asymmetry
  • deformities and cranial nerve injury (muscle palsy)
• inspect for malocclusion, bleeding, step off

Palpation

• tenderness
• step off (step in bone)
• facial stability
• crepitus
• subcutaneous air
• cutaneous anaesthesia, paraesthesia
• palpate the mandible for tenderness, swelling, step off

in order
periorbital

• check visual acuity
  • how many fingers / eyechart
• check pupils for roundness and reactivity to light
• examine eye/eyelids for lacerations
• test extra ocular muscles
  • full range of eye movement
• palpate around entire orbits
• change in sensation (supraorbital and supratrochlear)
• penetrating injuries
  • occult globe penetration (retinal haemorrhage)
  • eyelid laceration
• racoon eyes
  • bilateral periorbital eccymosis
  • likely skull base fracture concern

Nose

• septal cartilage, examining for septal haematoma
  • surgical emergency to evacuate haematoma, can cause necrosis of septal cartilage and permanent nasal deformity
• cerebrospinal fluid leak (CSF rhinorrhea)
  • clear fluid leak from nostril (skull base fracture)
  • need CSF test to pathology
  • referral to neurosurgeon

Ears

• battles sign
  • ecchymosis behind ear in mastoid process
  • likely basilar skull fracture
  • can lead to permanent brain injury, meningitis, etc
  • 

Oral and mandibular exam

• under tongue/floor of mouth
  • ecchymosis suggestive of fracture
• occlusion
  • open bite/ AOB suggestive of mandibular fracture
• palpate alveolus
  • tenderness with movement indicating fractured region
• break/breach in mucosa
  • fracture into mucosa
• mandible deviation
  • deviation to one side is contralateral condylar fracture
• paraesthesia
  • if involving IAN, tongue lip teeth
• tongue blade test
  • bite onto wooden spatula and pressure in biting should cause mandibular movement in fracture

Example cases

Mandible

Fracture pattern

• usually young male patient after blow to face
• angle of mandible 20-33%
• body of mandible 15-25%
• condlye of neck 15-36%
• parasymphaseal 14-15%
• ramus 5%
• coronoid process 1-3%
• alveolar ridge 2%
  Clinical exam
• can be associated with cervical spine fracture, extremely urgent
• can displace tongue
• step off in occlusion, likely mandibular fracture
  Classification
• 
• displaced / non displaced
• open / closed (piercing skin vs not)
• favourable / unfavourable (based on muscle pull direction)
• 
• 
  Radiographic interpretation
• ,
  Treatment options
• .
  Followup
• .

Orbit

Fracture pattern

• when projectile or fits hits the eye
• orbital rim fracture
  • bony outer edges of eye socket
  • typically car accident, takes a lot of force to break
  • optic nerve function to be checked
• blowout fracture
  • break in floor or inner wall of orbit/socket
  • can trap/pinch muscles/nerves around the eye
  • ball or fist
• orbital floor
  • trauma/blow causes orbital rim to push bones back, and bones of socket floor buckle downward
    Clinical exam
• urgent if (immediate surgical intervention)
  • associated with muscle entrapment (inferior rectus)
  • globe injury
  • retrobulbal haemorrhage
• usually through floor or medial wall
• hydrolytic theory where great sudden expansion forces are created from direct blunt trauma to orbit, which cause buckling of adjacent walls (thinnest parts are floor/medial)
• presents with
  • enophthalmos (sunken eye)
  • anaesthesia infraorbitally (infraorbital nerve)
  • diplopia (uncoordinated eye muscles)
  • infraorbital stepoff deformity
  • subcutaneous
• check for
  • muscle motility (all rectus muscles)
  • visual acuity (rule out damage to optic nerve)
  • check infraorbital nerve supply
  • gross inspection of area
    Radiographic interpretation
• ,
  Treatment options
• surgery
• consult ophthalm and macsfacs
• prophylactic antibiotics (likely contamination of maxillary sinus bacteria), nasal congestants, avoid valsalva and nose blowing
  Followup
• .

Riskf of orbital floor surgery

• retrobulbar haemorrhage
• 

Zygomaticomaxillary complex

Fracture pattern

• tripod fracture
  • zygo arch, infraorbital rim and lateral orbital wall
    Clinical exam
• .
  Radiographic interpretation
• ,
  Treatment options
• .
  Followup
• .

Maxilla

Fracture pattern

• leforte 1
  • floor of nose, hizontal fracture separating maxilla from pterygoid plates
• leforte 2
  • pyramidal, involving nasal bridge, maxilla, orbital floor
  • blow to lower maxilla/midmaxilla
  • extend from nasal bridge/nasofrontal suture
  • through frontal processes of maxilla
  • inferolaterally through lacrimal bones and inferior orbital floor and rim (near inferior orbital foramen),
  • inferiorly through anterior wall of maxillary sinus
  • under zygoma and across pterygomaxillary fissure through pterygoid plates
• leforte 3
  • transverse, entire midface separated from skull base
  • start at nasofrontal and frontomaxillary sutures
  • extend posteriorly along medial wall of orbit through nasolacrimal groove and ethmoid bones
  • continue along floor of orbit along inferior orbital fissure, continuing superolaterally through lateral orbital wall
  • through zygomaticofrontal junction and zygomatic arch
  • intranasally extending through base of perpendicular plate of ethmoid, through vomer, through interface of pterygoid plates to base of sphenoid

Clinical exam

• can produce massive haemorrhage
• can displace soft palate and cause airway compromise
• facial elongation and AOB
  • midface crush/lefort
• urgent if
  • airway compromise

Radiographic interpretation

• ,
  Treatment options
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  Followup
• .

Frontal

- outer table frontal sinus fracture penetrating into frontal sinus
- triangular fracture shape with intact inner table

• frontal sinus inner table communicates with cranial space
• frontal sinus drains through frontonasal duct into ethmoid sinus

Fracture pattern

• usually blunt trauma to front of face from motor vehicle accident or assault
• treatment depending on severity and displacement
• small fracture may be managed with minimally invasive incision
• large fracture hair line incision will full forehead retraction
• very thick bone with great force required to fracture
• classification
  • isolated anterior table/wall
  • combined anterior and posterior table/wall
  • with/without CSF leak
    Clinical exam
• consequence of fracture
  • direct brain injury
  • secondary brain injury due to bleeding at fracture site
  • frontal bone fracture may lead to tear of dura
• forehead depression
• inner table fracture with dura tear
  • intracranial injury
  • CSF leak
  • risk of meningitis
    Radiographic interpretation
• ,
  Treatment options
• neurosurgeon referral if concern of intracranial injury
• where frontal sinus remains functional (sinus lining intact and drainage patent), no sinus treatment required
• sinus affected
  • surgery indicated
    Follow up
• .

Nasoethmoid complex

Fracture pattern

• high impact force anterior to nose and transmitted posteriorly through ethmoid
• very complex area with many small bones, very difficult to treat and diagnose
  Clinical exam
• flattened nasal bridge or saddle shaped deformity of the nose
• widening of nasal bridge (telecanthus)
  • damage to inner canthal tendon of lacrimal bone
• concerns of CSF rhinorrhea or epistaxis
  • from fracture to cranial base
• tenderness, crepitus and mobility of nasal complex
• intranasal palpation reveals movement of medial canthus
  Radiographic interpretation
• ,
  Treatment options
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  Followup
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