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Intern’s Hour

Intern’s Hour. Maxillofacial Trauma Preceptor: Dr. Germar BLOCK R. The Case. 24-year-old male who sustained traumatic injuries during a soccer game DOI: 3/18/2010 TOI: 7 AM POI: soccer field MOI:

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Intern’s Hour

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  1. Intern’s Hour Maxillofacial Trauma Preceptor: Dr. Germar BLOCK R

  2. The Case 24-year-old male who sustained traumatic injuries during a soccer game DOI: 3/18/2010 TOI: 7 AM POI: soccer field MOI: Few hours PTC, the patient, a soccer goalkeeper, attempted to recover a loose ball when he was struck in the face by an opponent’s knee. After contact, the patient fell to the ground on his left side in a side-lying position.

  3. Review of Systems (-) LOC (-) seizure (+) headache (+) dizziness (-) vomiting (-) rhinorrhea/ epistaxis (-) otorrhea (-) dyspnea (-) chest pain (-) abdominal pain (-) urinary and bowel changes

  4. Physical Examination VS: BP 130/80, HR 86, RR 20, afeb HEAD and NECK: (+) R periorbital edema with subconjunctival hemorrhage, OD R facial swelling and tenderness (+) crepitus on R maxillary area (+) upper lip laceration (-) malocclusion, able to open mouth to 4 fingerbreaths

  5. Physical Examination HEART AP, DHS, NRRR, apex beat @ 5th ICS LMCL, (-) murmur CHEST and LUNGS ECE, CBS, (-) crackles/ wheezes ABDOMEN Soft, flat abdomen, NABS, (-) tenderness EXTREMITIES PNB, FEP, (-) cyanosi/ edema

  6. Physical Examination NEURO GCS 15 (E4V5M6), oriented to 3 spheres CN intact Motor strength 5/5 on all extremities (-) sensory deficit DTRs 2+, (-) Babinski Supple neck

  7. Assessment Multiple Injuries 2⁰ to --- 1. R periorbital contusion with subconjunctival hemorrhage of the R eye 2. t/c R maxillary fracture r/o intracranial injury

  8. Course Upon arrival at the ER, A: with the athlete in the supine position, an attempt to open the airway using a modified jaw-thrust maneuver was performed. B: the breathing can be compromised as a result of blood from ongoing facial bleeding. After blood was quickly cleared from the face, the source of bleeding was identified in the upper lip, which had sustained a complete through-and-through laceration. Direct pressure was immediately applied. C: blood pressure was noted to be normal, cervical spine was secured

  9. Diagnostics CBC Blood type PT/PTT Na, K, Cl, BUN, Crea

  10. Diagnostics Towne’s, Water’s, SMV radiographs of the chest, cervical spine The radiographs revealed no evidence of vertebral fracture or pulmonary disease computed tomography (CT) scans of the brain and face

  11. CT scan The CT scans identified fractures of the anterior, posterior, and medial walls of the right maxillary sinus. A small pocket of air was identified in the right infratemporal fossa, suggesting an occult fracture of the lateral wall of the right maxillary sinus. The initial facial CT scan also suggested a fracture of the floor of the right orbit. The cranial CT showed no evidence of skull fracture or intracranial injury.

  12. Final Diagnosis Multiple Injuries 2⁰ to --- 1. R periorbital contusion with subconjunctival hemorrhage of the R eye 2. R maxillary fracture

  13. Maxillofacial Trauma

  14. Anatomy

  15. Anatomy

  16. Maxillofacial Region 1. Fractures of the Nasal Pyramid 2. Fractures of the Central Midface • Le Fort Fractures

  17. Maxillofacial Region 3. Fractures of the Lateral Midface 4. Fractures of the Frontal bone 5. Fractures of the Anterior Skull Base • Escher Classification

  18. Maxillofacial Region 6. Fractures or dislocation of the mandible

  19. Etiology • Sports • Vehicular Accidents • Mauling • Women – consider the possibility of domestic violence

  20. Etiology • Patients with severe facial trauma: • multisystem trauma • potential for airway compromise • concurrent brain injury • cervical spine injuries • blindness

  21. Emergent Management • Primary Survey • Airway • Breathing • Circulation • Secondary Survey

  22. Emergent Management Airway: • Chin lift. • Jaw thrust. • Oropharyngeal suctioning • Manually move the tongue forward • Maintain cervical immobilization

  23. Emergent Management • Avoid nasotracheal intubation • Adverse effects: • Nasocranial intubation • Nasal hemorrhage •  cricothyroidotomy

  24. Emergent Management Circulation: • Direct pressure • Anterior and posterior nasal packing • Packing of the pharynx around ET tube

  25. History • Place, Time, Date, Mechanism of injury • Detailed description of the circumstances surrounding the injury • Allergies, other medical problems, medications, tetanus immunizations

  26. History • Questions: • Was there LOC, nausea/vomiting, headache? (Head Trauma related questions) • How is your vision? • Hearing problems? • Is there pain with eye movement? • Are there areas of numbness or tingling on your face? • Able to bite down without any pain? • Is there pain with moving the jaw?

  27. Physical Examination Inspection • Open wounds for foreign bodies • Facial asymmetry • Nose for deviation, widening of bridge • Nasal septum for septal hematoma, CSF or blood • Ears for blood or CSF • Malocclusion

  28. Physical Examination Inspection • Raccoon eyes • Battle’s sign

  29. Physical Examination Inspection • Halo Sign • Not sensitive or specific but can be used as a preliminary test for CSF in blood • Dipstick • Beta transferrin • Otorrhea, Rhinorrhea

  30. Physical Examination Palpation • Palpate the entire face. • Supraorbital and Infraorbital rim • Zygomatic-frontal suture • Zygomatic arches • Nose - crepitus, deformity and subcutaneous air • Zygoma along its arch and its articulations with the maxilla, frontal and temporal bone • Mandible for tenderness, swelling

  31. Physical Examination • Intraoral examination: • Inspect the teeth for malocclusions, bleeding • Manipulation of each tooth • Check for lacerations • Mandibular movements

  32. Physical Examination Ophthalmologic exam • Visual acuity • Pupils for shape and reactivity • Eyelids for lacerations • Extra ocular muscles • Palpate around the orbits

  33. Physical Examination • Examine and palpate the exterior ears • Otoscopic examination • Look for lacerations • TM rupture

  34. Diagnostic Imaging • Plain films • Confirm suspected clinical diagnosis • Determine extent of injury • Document fractures • CT scan

  35. General Treatment • ATS, TeAna • Thorough evaluation of all wounds • All foreign bodies must be removed • Debridement • Suturing of lacerations as needed • Minimize scarring • Antibiotics

  36. Nasal Fractures • Most common bone injury in the face • Open or closed • Signs • Depression or displacement of nasal bones • Edema of nose • Epistaxis • Fracture of septal cartilage with displacement or mobility • Crepitus on palpation

  37. Nasal Fractures • All nasal injuries should be evaluated for septal hematoma • Untreated- result in septal necrosis and saddle nose deformity • Can become infected- result in a septal abscess

  38. Nasal Fractures • Radiographs: • Lateral projection • Treatment: • Surgical • After reduction, nasal cavities should be packed – “internal splinting”

  39. Maxillary Fractures • Le Fort’s classification • Le Fort I (transverse maxillary) • Le Fort II (pyramidal) • Le Fort III (craniofacial dysjunction)

  40. Le Fort I • Low transverse fracture of maxilla involving palate • Facial edema • Mobility of hard palate and upper teeth • Malocclusion

  41. Le Fort II • Pyramidal fracture with detachment of maxilla • Facial edema • Epistaxis • Bilateral periorbital edema and ecchymosis

  42. Le Fort III • Complete disruption of attachments of facial skeleton to cranium • Movement of all facial bones in relation to the cranial base with manipulation of the teeth and hard palate • Open patient’s mouth and grasp the maxilla arch • Place the other hand on the forehead • Gently move back and forth, up and down - check for movement of maxilla

  43. Le Fort III

  44. Le Fort III • Massive edema with facial elongation, flattening – “Dish faced deformity” • Epistaxis and CSF rhinorrhea • Motion of the maxilla, nasal bones and zygoma

  45. Management of Le Fort Fractures • Open reduction and intermaxillary fixation should be performed to establish correct occlusion • Followed by rigid fixation at the piriform rims and zygomaticomaxillary buttress.

  46. Zygoma Fractures • The zygoma has 2 major components: • Zygomatic arch • Zygomatic body • Two types of fractures can occur: • Isolated Arch fracture -most common • Tripod fracture - most serious

  47. Zygoma Arch Fractures • Palpable bony defect over the arch • Flattening of the cheek • Pain in cheek and jaw movement • Limited mandibular movement

  48. Zygoma Arch Fractures • Radiographic imaging: • Submental view “bucket handle view” - Arches may not be seen in usual views (anterior, lateral) • Treatment: • Symptomatic - surgical

  49. Zygoma Tripod Fractures • Tripod fractures consist of fractures through: • Zygomatic arch • Zygomaticofrontal suture • Inferior orbital rim and floor • Symptoms • Periorbital edema • Sensory disturbances along the infraorbital nerve

  50. Zygoma Tripod Fractures • Waters • Caldwell • Submental • Coronal CT • Treatment: • Symptomatic - surgical

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