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Facial trauma

Facial trauma

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Facial trauma

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  1. Facial trauma 1393/3/5

  2. Isfahan university of medical sciences M: SONBOLESTAN MD

  3. MANAGEMENT OF FACIAL TRAUMA

  4. PRIMARY SURVEY A. Airway and C-spine control B. Breathing and ventilation C. Circulation and hemorrhage control D. Disability E. Exposure M. Monitor

  5. LIFE-THREATENING CHEST INJURY 1. Airway obstruction 2. Tension pneumothorax 3. Open pneumothorax 4. Massive hemothorax 5. Pericardiac tamponade 6. Flail chest combined pulmonary contusion

  6. SECURE AIRWAY • Assist airway Oral airway, nasal airway, LMA • Endotracheal intubation Oral, nasal • Surgical airway Cricothyroidotomy Tracheostomy

  7. LIFE-THREATENING HEAD INJURY • Intracranial hemorrhage Epidural hematoma, subdural hematoma, intracerebral hematoma, subarachnoid hematoma • Diffuse axonal injury • Management a. Evacuation of hematoma b. Decrease IICP and mass effect c. Maintain cerebral perfusion

  8. I I C P • Symptoms Headache, vomiting, consciousness change • Signs Increase BP, decrease HR & PR papilledema • Neurological findings Focal sign, pupil size and light reflex

  9. WOUND CARE 1. Copious irrigation 2. Remove foreign body 3. Antiseptic solution 4. Adequate debridement 5. Primary / Delayed suture

  10. LIFE-THREATENING ABDOMINAL INJURY 1. Liver laceration 2. Spleen laceration 3. Large vessel injury 4. Pelvic fracture

  11. TRAUMATIC SHOCK 1. Hypovolemic shock 2. Neurogenic shock 3. Cardiogenic shock 4. Septic shock

  12. FLUID RESUSCITATION 1. Access Two large bore IV catheter 2. Fluid Crystalloid, colloid, blood component 3. Amount a. Bolus: 2 liter for adults 20 ml/ kg for child b. maintain amount based on urine output

  13. THREATENING EXTREMITY INJURY 1. Femoral fracture 2. Multiple fracture 3. Nerve, vessel, muscle and soft tissue injury

  14. THERMAL INJURY 1. Major burn 2. High-voltage electric injury 3. Inhalation injury 4. Chemical burn

  15. ACUTE ABDOMEN • Differential diagnosis Surgical abdomen / medical abdomen • Pain history Onset, location, intensity, duration, radiation, quality, associated symptoms • Symptoms sequence

  16. Urological Emergency • Painful conditions • Bleeding conditions • Trauma conditions • Others

  17. REEVALUATION • Time interval • Same personnel • Vital signs • Laboratory examination • Early suspicion • Early consultation

  18. MEDICAL ETHICS • Treat a person not a disease • Treat a patient as your family • Be patient to a patient’s complaint • Be kind and more smile • Careful explanation

  19. Frontal sinus fracture Frontal sinus Drains into nasal cavity via fronto-nasal duct An air filled cavity lined by ciliated respiratory epithelium encased in the frontal bone 19

  20. Extent of the injury: Anterior table Posterior table Associated injuries: mid-face or head injuries e.g. Le Fort II, III NOE Neuralgic insults Ocular injuries 20

  21. Diagnosis Clinical examination Radiographical evaluation Occipitomental views Lateral skull view CT scan 21

  22. Classification of fractures Anterior table fracture Linear Displaced Posterior table fracture Linear Displaced Outflow tract injury (naso-lacrimal duct) 22

  23. Surgical management Intranasal cannulation Frontal sinus trephination Osteoplastic flap Sinus ablation (obliteration) Cranialization Reduction and fixation 23

  24. Reduction and fixation Surgical approaches: Site of penetrating injury Coronal approach 24

  25. Sinus ablation (obliteration) Fat Muscle and fascia Bone Alloplastic materials 25

  26. Fixation Wires Plating 26

  27. Nasal fractures Anatomy Midline central facial structure that fulfills both cosmetic and functional purposes Formed by union of rigid and flexible struts 2 rectangle-shaped nasal bone ULCs, LLCs and midline septal cartilage 27

  28. Classification of injuries Low energy injuries Simple injury caused by low velocity trauma (simple noncomminuted) High energy injuries Severe injury with comminution of nasal facial Skelton due to higher amount of energy • Patterns of injury • Lateral injury (from the side) • Sagittal injury (from the front) • Inferior injury (from below) 28

  29. Treatment Low energy injuries Reduction (close manipulation, open reduction) and stabilization Nasal packing External nasal splint Adjunct septoplasty Postoperative care 29

  30. Complex injuries Immediate measures: Extra and intranasal examination Identification of extra and intranasal lacerations Identification and control of site bleeding Surgical procedures: Open septal procedures Open nasal procedures Open rhinoplasty Open-sky “H” technique 30

  31. Nasal fractures • Nasal bone fractures • Nasal aperture fractures

  32. Nasal bone

  33. Nasal bone fractures

  34. Nasal aperture fracture

  35. Types of aperture fractures

  36. Nasal-orbital ethmoid injuries They represent a wide spectrum of injuries Simple nasal fracture with involvement Of orbital bones Grossly comminuted and compound naso-orbital ethmoid fracture involving the base of skull with significant displacement 36

  37. Diagnosis Clinical examination: Obliterating swelling Canthus detachment Lacrimal apparatus damage Deformity of nasal bridge CSF leak Radiographical examination: Occipitomental views Lateral skull views CT and 3D CT 37

  38. Management of nasal-orbital ethmoid fractures Examination for determination of the extent of the injury (surgical exploration) Nasal bone Orbital and ethmoidal Frontal bone Debridement and closure of open wounds Reduction and stabilization of bone fracture 38

  39. Detached canthusTraumatic telecanthus Increase in inter-canthal distance secondary to canthus displacement or detachment Seen in association to: Nasal bone NEO Le Forts fractures 39

  40. Surgical management of detached canthus Transnasal wiring technique (unilateral type) Canthopexy Identification of the ligament Liberation of the periorbital tissue Liberation of the lacrimal pathway Nasal transfixation Contralateral fixation 40

  41. Lacrimal duct system injury The lacrimal sac can be torn by fragments of a comminuted fracture Or Compressed by a mass of callus which may block the nasolacrimal canal EPIPHORADacryocystitis 41

  42. Reconstitution of the lacrimal passages Done at the same time of canthopexy via The original scars Lateral nasal incision (Lynch) Bi-coronal incision Dacryocystorhinostomy If the sac remains intact, drainage of lacrimal fluid by probing or removing of surrounded bone to allow drainage into the nose Conjunctivo-rhinostomy implantation of a duct-like polythene tube or glass in case of duct damage 42

  43. Blow out fractures

  44. Conventional radiography

  45. CT of blow-out fractures of orbital floor

  46. Blow-out and orbital emphysema

  47. Blow-out through lamina papyracea

  48. Uttalt pneumatisering av frontalsinus

  49. Blow-out fracture upwards

  50. Upward blow-out Roof fracture