MEMENTO MORI
MAXILLO-FACIAL TRAUMA R. Drummond October 24, 2002 preceptor: Carol Holmen
Overview n n n n General approach to facial trauma Epidemiology anatomy diagnostic imaging specific conditions diagnosis of facial trauma as a presentation of abuse Conclusions
General Comments n n n n Injuries to the face devastating to patient physical, emotional, occupational, sequelae Two presentations simple, isolated injuries clinically stable vs. Manifestation of severe trauma 25% of maxillofacial trauma involves litigation most injuries can be picked up on thorough clinical assessment Our role is usually to diagnose not treat Overlap of specialists ENT, OPHTH, PLASICS, NEUROSURGERY, DENTISTRY
Question 1: The single most valuable xray of the mid-face is: n n 1)Water’s view 2)Lateral view 3)Caldwell view 4)Towne’s view
Question 2 : Most associated injuries in cases of maxillofacial trauma are to the: n n 1)brain 2)cervical spine 3)chest 4)abdomen
Question 3: Open bite may be secondary to all except: n n 1)Le. Fort Fracture 2)tripod fracture 3)mandibular fracture 4)NEO fracture
Question 4: All of the following are true about children with maxillo facial trauma except n n 1)greater risk of lower cervical spine injury 2)intracrainial injury is higher 3)mid-face fracture higher as child grows 4)non-accidental trauma should be considered
Triage scenario n n n Two vehicle head on collision, driver and front seat passenger in one vehicle, single driver in second vehicle cars each going 30 m. p. h. all were unrestrained all brought to ED by EMS all on spinal boards
Patient 1 n n n 5 year old child passenger of car windshield fractured in target pattern No LOC Large Laceration across forehead , boggy swelling of skin, moderate “watery” epistaxis HR 140 BP 90/45 RR 34 (crying) sats 100% GCS 15
Patient 2 n n n 26 year old woman, was driver of the car face hit steering wheel. . . No L. O. C. Badly injured face, no other obvious injuries gasping “I have to sit up I can’t breathe” vitals HR 120 BP 90 /40 RR 36 Sats 89 on 10 litres GCS 14 primary survey gurgling resps with considerable blood in mouth gaping wounds across forehead jaw is mangled with evident deformity
Patient 3 n n n 18 year old driver of other vehicle works as a miniaturist painter, lost his bottle -bottom spectacles at scene of accident hit driver’s side window No L. O. C. HR 100, BP 120/75 RR 24 sats 98% GCS 15 badly lacerated L face with deformity tender over zygoma diplopia numbness over cheek positive Marcus Gunn
Force of Gravity Necessary to Injure Face n n n Nasal Bones 30 x gravity Zygoma 50 x gravity Angle of Mandible 70 x gravity Frontal Globellar region 80 x gravity Midline Maxilla 100 x gravity Supraorbital rim 200 x gravity
Basic Epidemiology n n n Most common causes: MVA’s, falls, assault community: nose and mandible F n urban: F n : MVA’s and Sports midface, zygoma penetrating and assault more than 60% have associated F other injuries
MVA
Epidemiology of Maxillo. Facial Injuries at Trauma Hospitals in Ontario, Canada between 1992 and 1997 al n n n n The Journal Of Trauma, September 2000. . . Hogg et Ontario Trauma Registry new database 15 -22 % of trauma patients severe maxillofacial injuries 2, 969 patients in 12 trauma centers male: female 3: 1 most common cause mva’s 26% positive BAC understanding causes severity temporal distribution effective treatment and prevention
ASSOCIATED INJURIES
TYPE OF FRACTURES
MONTH
TIME OF DAY
AGE AND GENDER
Long Term Physical Impairment and Functional Outcomes after Complex Facial Fractures Plastic and Reconstructive Surgery, August 2001 Girotto, Mac. Kenzie et al n n n Retrospective cohort study of adults 18 - 25 265 pts with Le. Fort fractures compared to 242 pts with severe general injury followed with several tools to assess health and well being (General Health Questionnaire, Body Satisfaction Scale, Social Avoidance and Distress Scale) hypothesis early intervention at tertiary care trauma center better results complex facial fractures represent subset of trauma with more longterm complications
n n n n Obvious sequelae: Diplopia 56% Zygomatic fractures 23% Le. Fort fractures 20 -31% midface fractures difficulties mastication 35% Anasomia in Le. Fort Fractures Epiphora midface fractures 25 - 45 % facial numbness 32 -35 % 55% of facial fractures returned to work at one year compared to 70% less severe facial fractures other general injuries
n “An appreciation of the long term physical and psychological sequelae of injury is essential for evaluating current treatment plans and to assist in providing appropriate counseling or referral to other healthcare professionals”
Triage and immediate management n n n n Airway management first and major priority be prepared for surgical airway clear cervical spine then let patient adopt most comfortable position caution re nasal tracheal intubation if RSI prep for cricothyroidectomy awake intubation ketamine a good drug tongue often obstructs
Shock and Hemorrhage n n n Maxillofacial Trauma seldom cause of shock 60% association other injuries If shock check for other sources with severe facial smashes reduce fracture plates severe epistaxis hard to control : Foley
n All patients with significant facial injuries must be presumed to have cervical spine injury until proved otherwise
History n n n n n Mechanism of injury blunt vs. Penetrating L. O. C. ? questions: Do you see double? Are there areas of numbness on your face? Does your bite feel normal? Which areas on your face hurt? Does it hurt when you open your mouth and where? Consider abuse
Physical Exam n n n n n Inside Out and bottom up bird’s eye view and worm’s eye view Gestalt 90% of all facial fractures can be picked up or suspected by careful palpation careful ocular exam visual acuity fields subconjunctival hemorrhage Pinpoint exam, Marcus Gunn exam raccoon eyes, battle sign halo test intranasal palpation test
n n Allergies Tetanus status
Anatomy n n Vertical buttresses: nasal, frontal, and zygomatic maxillary give vertical stability zygomatic temporal buttresses horizontal support
Three Zones of Facial Anatomy n n n UPPER: Superior Orbit and above Frontal Bone MIDDLE: Superior Orbital rim to occlusal surface Orbits, Nasal bones, Zygoma, Maxilla LOWER: mandible, teeth clinical exam should guide and direct radiological exam
FACIAL BONES
NERVES OF FACE
Diagnostic Imaging n n n n Standard Four Views Waters Caldwell Lateral Submentovertex Occlusal views Panorex
Waters View n n n Most valuable prone. . Clear c-spine draw four lines should be parallel and smooth
WATERS VIEW
WATERS VIEW
WATERS VIEW PARALLEL LINES
Caldwell View n n n Supplements Waters view superior orbital rim sinuses orbital region can see teardrop sign open bomb bay door sign
CALDWELL VIEW
CALDWELL VIEW
Lateral View n n n Frontal Sinus maxillary sinus occasionally pterygoid plate
LATERAL VIEW
Submentovertex view n n “Jughandle” view Main value is to see zygomatic arch
SMV VIEW
n n n X-rays good screening test to guide which CT scan to order and level Ctscan most useful to grade injury and plan surgery most useful for orbital and maxillary fractures blowout fractures in particular axial and coronal can do 3 -D reconstruction
Lefort III
DENTAL PANOREX
PEDIATRIC DENTAL PANOREX
18 year old girl playing catcher at slopitch baseball game hit in forehead by baseball bat large laceration with swelling forehead 3 min LOC
n n What to look for on exam? ? Crepitation, subcutaneous emphysema, soft doughy feel check laceration carefully check for csf in nose halo sign
Frontal Bone Injuries - Anatomy n n n Proximity to brain, nose, orbits outer table thicker than inner dura forms inner periosteum intracranial injuries esp if posterior wall one study 89% significant frontal bone fractures eye problems including blindness
FRONTAL BONE
FRONTAL BONE
FRONTAL BONE #
FRONTAL BONE #
FRONTAL BONE #
Investigations n n Skull films useful if xray positive Ctscan
Management n CNS or ENT consult n ? ? Antibiotics n if yes, first generation cephalosporin clavulin or septra n anterior wall elevation for cosmesis n
32 year old male partying at Dutch Creek campground pitched tent on sixty foot cliff drank twelve beer and smoked two joints got up at 4 am to take a leak. . . He hit the bottom before his pee. Four hour rescue operation in the dark. After trip to local hospital full work up showed only large ecchymosis and swelling over base of nose noted to have continuous tearing left eye double vision
n n n n NASO-ORBITAL-ETHMOIDAL (NOE or NEO) FRACTURE Zone between cranial, orbital, and nasal cavities disorganization of skeletal structure check intercanthal distance. . Telecanthus intranasal palpation test CSF rhinorrhea septal hematoma fine cut Ctscan coronal sections
Nasal Bone Fractures n n Three questions Have you ever broken your nose before? How does your nose look to you? How is your breathing?
# NASAL BONES
NASAL BONE #
Findings n n n n n Crepitus, hypermotility, edema, tenderness, deformity depressed vs. Laterally angulated vs comminuted if mechanism severe look for other injuries control epistaxis look for septal hematoma. . . Drain are xrays necessary if early: reduce with simple pressure if late: needs operative repair f/u with plastics more important than x-ray
Pediatric Concerns n n Bones not fused can develope growth retardation if significant needs complete reduction f/u plastics in 4 days
28 year old bungee cord jumper in Australia jumping off bridge in the dark 100 feet hit surface of water went three feet under water. . . Ok that night next day very swollen face double vision on exam could not get left eye to look upward
BUNGEE CORD JUMPER
BUNGEE JUMPER BLOWOUT
ORBITAL BONES - what is bone 3 called? ?
BONES OF THE ORBIT
ORBIT: ANATOMY
ORBIT: ANATOMY
Orbital Fractures n n n n After life-saving measures preservation of eyesight next main priority blunt trauma to orbit or globe seven bones in orbit any guesses? frontal, zygoma, sphenoid, ethmoid, maxilla, palatine. . . and lacrimal cone or pyramid in shape design feature
BLOWOUT LEFT EYE ENTRAPMENT
EOM ENTRAPMENT IN BLOWOUT
BLOW OUT TEARDROP SIGN
ORBITAL BLOWOUT
BLOW OUT AIR FLUID LEVELS
n n n Dangerous triad decreased field, double vision, decreased visual acuity distinguish pure from impure orbital fractures pure orbital fracture synonymous with Blow Out first called this by Smith and Regan 1957 first described in 1844
n n n Ask: Do you have double vision? Do you have numbness cheek, lip, mandibular teeth often examiner neglects superior and lateral rim of orbit subcutaneous emphysema pathognomonic for rupture into maxillary sinus
PERIORBITAL EMPHYSEMA
Diplopia n Complicated by edema, blood, temporary neuromuscular injury, change in orbital shape, third nerve palsy entrapped EOM does not resolve forced duction test n Enophthalmosis : retraction of eye into socket n n
investigations n n n Xray finding Caldwell teardrop sign open bomb bay door sign air/fluid level in maxillary sinus CT scan definitive
BLOWOUT
MEDIAL WALL BLOWOUT
CORONAL SLICES THROUGH ORBIT
BLOWOUT FRACTURE
Management n n n Any questionable midface injury consult ophthalmologist many delay repair for two weeks AB if subcutaneous emphysema do not blow nose rare malignant periorbital emphysema lateral canthotomy
The Diagnosis and Management of Orbital Blowout Fractures Update 2001 Brady, Mc. Mann et al. , American Journal of Emergency Medicine n n n n 100 Blowout Fractures 59 pure blowout fractures age 8 to 75 falls, aggression, and sports periorbital ecchymoses, diplopia, hypoesthesia in V 2 intraorbital emphysema plain xrays 13/26 false negative only 5 true positives CT 51/59 true positives
n n n Implants 35/55 cases lyophilized bovine before 1996 controversy in 1971 and 1974 most enophthalmosis and diplopia spontaneously resolve orbital floor repair dangerous n current recommendations: surgery if diplopia from entrapment not gone 2 weeks enophthalmosis greater than 2 mm orbital floor greater than 50% blown out n (unacceptable cosmetic results) n n n
n n n n n Do not recommend plain xrays direct Ctscan cold packs x 48 hours use of nasal decongestant no ASA no nose-blowing Steroids broad spectrum antibiotics transconjunctival approach
56 year old male street person drank a little too much Mogen. David kicked in face as he slept on heating grate swollen left face subconjunctival hemorrhage lateral deviation of eye
ZYGOMA FRACTURE
ZYGOMA TRIPOD #
ZYGOMA TRIPOD #
ZYGOMA TRIPOD FRACTURE
TRIPOD FRACTURE
ZYGOMA ARCH FRACTURE
ZYGOMA ARCH #
3 D RECONSTRUCTION # ZYGOMATIC ARCH
Cause n n n Second most common facial fracture after nasal bones tripod vs arch articulates with maxilla, frontal and temporal bones tripod more serious arch more common
What Questions to ask n n Does it hurt to open your mouth? Is your lower lid, cheek, teeth numb?
MASSETER MUSCLE
Findings n n n n Masseter attachment pulls bone lateral and inferior vertical dystopia ipsilateral epistaxis edema masks deformity check for symmetry check inside of mouth for tenderness zygomatic arch
Investigations n n n Single Waters view submentovertex view Ctscan definitive
Management n n Rule out ocular injury admit tripod fracture OPD for arch fractures f/u for plastics elevated with Gilles elevation
44 year old thrown off motorcycle ruptured spleen required 14 units PRBC’s third day in ICU on ventilator noted to have badly swollen ecchymotic skin around face with unusual distortion (according to sister) massive bruising around eyes
Maxillary Fractures n n n n Huge amounts of energy high association with other injuries classification system Le. Fort I, III IV usually seen in textbooks in practice combinations of the above can be “greenstick” or impacted they all involve malocclusion
MAXILLARY FRACTURE
LEFORT I II AND III
LEFORT I
LEFORT II
LEFORT III
LEFORT II AND III
Questions if Conscious? n n n Does your bite feel normal? Is your lip numb? Does your jaw hurt? Where? Site of premature contact points to fracture site disruption of periosteum
Investigations n n n Plain films not useful plain waters view any haziness or any suspicion CTScan 2 - 3 mm coronal cuts if intracranial air open skull fracture
Management n n n n Usually given antibiotics does not usually in itself cause airway obstruction sometimes needs aggressive airway management nasal packing can distract fracture foley catheter with saline pushing fracture back into place stops bleeding Le. Fort II and greater ORIF
38 year old woman won’t make eye contact not forthcoming how she was hurt. . . Cannot open or close mouth without severe pain swollen over angle of left jaw
Mandibular Fractures n n n n Fractures chin points to side of injury dislocation chin points away from injury located to symphysis, body angle, condyle or subcondylar area third most common fracture, after, nose and zygoma At least half of mandibular fractures multiple second fracture often distal open book fracture symphysis plus bilateral condyles
MANDIBULAR FRACTURES
MANDIBULAR #
MANDIBULAR FRACTURE
COMBINATION FRACTURE MANDIBLE
FRACTURED MANDIBLE
MANDIBLE FRACTURE
MANDIBULAR FRACTURES
FRACTURED MANDIBLE AT ANGLE
Questions: n n n How is your bite? Does your jaw hurt? Where? Is your lower lip and or chin numb?
Investigations n n Tongue Depressor test plain films esp panorex usually adequate
Management n n n Compound Fracture by definition needs surgery needs antibiotics 24 g wire two teeth Barton’s bandage
# MANDIBLE REPAIRED
43 year old epileptic found post ictal (29 second seizure) confused cannot speak properly dysarthric mumbling cannot close mouth
n n n Chin deviates away from dislocation occ’l bilateral dislocation chin juts forward if trauma x-ray before re-location barton’s bandage immediately surgery if pain, spasm, , tenderness especially if first time
TMJ DISLOCATION
Dental Avulsions n n n n n Three levels of injury to teeth enamel, dentin (yellow) pulp dental pulp immediate referral to dentist to avoid abscess if avulsed time is of essence transport under tongue in milk or saline gentle rinse avoid root area works best if re located 20 mins root does not survive greater than 2 hours once clean replace immediately
Special considerations paediatric facial #’s n n n Relatively rare if injured: frontal bone not mid-face, not mandible associated injury upper c-spine not lower SCIWORA worries about post injury dysplasia not scientifically confirmed micrognathia, asymmetry some re modelling nasal bones a concern
n n n n n More common if child less than three nasal bone fracture common TWO COMMON ERRORS failure to recognize more serious facial injury failure to recognize septal hematoma at age twelve to fifteen sinuses pneumatize incidence of mid-face fractures pick up bones set quickly early f/u 4 days any question about injury that can lead to growth retardation early f/u
Use of Antibiotics in Maxillo. Facial Fractures n “Whether one should administer antibiotics for CSF rhinorrhea and if so which one, is usually a decision made by the neurosurgeon and usually is based on personal preference rather than scientific data”. . . Emergency Medicine Clinics of North America
Practice Guidelines Vanderbilt University: Antibiotic Prophylaxis in Cranio-Facial Trauma n n n ICP Monitor and ventriculostomies: Ancef 1 gm iv prior to insertion then q 8 x 3 doses CSF leak: No prophylactic AB use Pneumocephaly: No prophylactic AB use Open-facial fractures: Clindamycin and gentamycin given preop and post op x 24 hours benefits not substantiated by literature
Awareness of Maxillofacial Trauma as a Manifestation of Abuse to Children, Women and the Elderly n Child Abuse : “ The intentional physical, sexual, or emotional mistreatment or neglect of a child under the age of 18 by a parent, legal guardian or caregiver that results in the injury or emotional detriment of the child “
n 1% of pediatric population n Age 0 -5. . 17% 6 - 14. . . 57% 15 -17. . 26% n 75 % of fatalities happen to children under five years of age n n
n n History in family background findings in child’s behaviour n common facial fractures: dental fractures, oral bruises, oral lacerations mandibular or maxillary fractures oral burns, avulsed teeth n dental x-rays multiple healed fractures n n n
SPOUSAL ASSAULT n n n n 20% Of relationships 10 : 1 Female : Male most injuries to face and head 30% of suicides 30% of homicides most likely to seek help from physician (especially emergency physician)
n Lacerations head and face hair loss, fractured teeth fractured jaw, isolated facial fractures bite marks, black eyes n injuries without explanation n
Abuse of the Elderly n n n Be aware of neglect dental caries, cheilitis poor hygiene, unkempt appearance perpetrator often direct care-giver caution with hostile unconcerned caregiver eg: inability or unwillingness to arrange appropriate follow-up
Question 1: The single most valuable xray of the mid-face is: n 1)Water’s view
Question 2 : Most associated injuries in cases of maxillofacial trauma are to the: n 1)brain
Question 3: Open bite may be secondary to all except: n 4)NEO fracture
Question 4: All of the following are true about children with maxillo facial trauma except n 1)greater risk of lower cervical spine injury
n TAKE HOME POINTS n Huge amount of force to injure face: watch for other injuries n MVA’s major cause of injury: strategies to prevent injuries n Major Long Term Sequelae both physical and personal
TAKE HOME POINTS n n n Shock is from another system usually not face Complicated airway problems need immediate attention 90% of fractures can be found with careful palpation
TAKE HOME POINTS n Waters view overall most useful view mid face n Panorex most useful view for mandible n CTScan most useful modality for Orbits and Maxilla
TAKE HOME POINTS n Frontal Bone Fracture takes lots of force check intracranial and eye status n NOE fractures orbital fractures by definition n Nasal fractures - check for and drain septal hematomas
TAKE HOME POINTS n Orbital injury urgent referral needs Ctscan n Zygoma fractures arch common, tripod serious n Le. Fort fractures are rarely classic in presentation
TAKE HOME POINTS n n n Fractured jaw chin points to side, dislocated jaw points away Immediate replacement for avulsed teeth Prophylactic antibiotics not necessary facial fractures
TAKE HOME POINTS n n Think of growth retardation in facial fractures kids If you see facial injuries think abuse in children, women, elderly
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