Facial trauma
1393/3/5
Isfahan university of medical sciences
3
PRIMARY SURVEY
A. Airway and C-spine control
B. Breathing and ventilation
C. Circulation and hemorrhage control
D. Disability
E. Exposure
M. Monitor
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
SECURE AIRWAY



Assist airway
Oral airway, nasal airway, LMA
Endotracheal intubation
Oral, nasal
Surgical airway
Cricothyroidotomy
Tracheostomy
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
IICP



Symptoms
Headache, vomiting, consciousness
change
Signs
Increase BP, decrease HR & PR
papilledema
Neurological findings
Focal sign, pupil size and light reflex
WOUND CARE
1. Copious irrigation
2. Remove foreign body
3. Antiseptic solution
4. Adequate debridement
5. Primary / Delayed suture
LIFE-THREATENING
ABDOMINAL INJURY
1. Liver laceration
2. Spleen laceration
3. Large vessel injury
4. Pelvic fracture
TRAUMATIC SHOCK
1. Hypovolemic shock
2. Neurogenic shock
3. Cardiogenic shock
4. Septic shock
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
THREATENING
EXTREMITY INJURY
1. Femoral fracture
2. Multiple fracture
3. Nerve, vessel, muscle and soft
tissue injury
THERMAL INJURY
1. Major burn
2. High-voltage electric injury
3. Inhalation injury
4. Chemical burn
ACUTE ABDOMEN



Differential diagnosis
Surgical abdomen / medical abdomen
Pain history
Onset, location, intensity, duration,
radiation, quality, associated symptoms
Symptoms sequence
Urological Emergency




Painful conditions
Bleeding conditions
Trauma conditions
Others
REEVALUATION






Time interval
Same personnel
Vital signs
Laboratory examination
Early suspicion
Early consultation
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
Frontal sinus fracture

Frontal sinus
An air filled cavity lined by ciliated respiratory
epithelium encased in the frontal bone
Drains into nasal cavity via fronto-nasal duct
19
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
Diagnosis

Clinical examination

Radiographical
evaluation



Occipitomental views
Lateral skull view
CT scan
21
Classification of fractures

Anterior table fracture



Posterior table fracture



Linear
Displaced
Linear
Displaced
Outflow tract injury (naso-lacrimal duct)
22
Surgical management

Intranasal cannulation

Frontal sinus trephination

Osteoplastic flap

Sinus ablation
(obliteration)

Cranialization

Reduction and fixation
23
Reduction and fixation

Surgical approaches:

Site of penetrating injury

Coronal approach
24

Sinus ablation
(obliteration)




Fat
Muscle and
fascia
Bone
Alloplastic
materials
25

Fixation


Wires
Plating
26
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
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
Treatment

Low energy injuries

Reduction (close
manipulation, open reduction)
and stabilization

Nasal packing

External nasal splint

Adjunct septoplasty

Postoperative care
29

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
Nasal fractures


Nasal bone fractures
Nasal aperture fractures
Nasal bone
Nasal bone fractures
Nasal aperture fracture
Types of aperture fractures
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
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
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
Detached canthus
Traumatic telecanthus
Increase in inter-canthal distance
secondary to
canthus displacement or detachment


Seen in association to:
Nasal bone
NEO
Le Forts fractures
39
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
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
EPIPHORA
Dacryocystitis
41
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
Blow out fractures
Conventional radiography
CT of blow-out fractures of orbital
floor
Blow-out and orbital emphysema
Blow-out through lamina papyracea
Uttalt pneumatisering av frontalsinus
Blow-out fracture upwards
Upward blow-out
Roof
fracture
Internal orbital fractures

In conjunction with other facial
fractures

As isolated type (Blow out
fracture)
52
Anatomy
The floor is made of:
Maxillary bone and
part of zygoma
bounded laterally by
the inferior orbital
fissure and small part
of the ethmoid bone
53
Clinical and radiographical presentation

Subconjunctival ecchymosis

Crepitation from air emphysema

Displacement of palpebral fissure

Unequal pupillary levels

Diplopia
enophthalmos

54


Diplopia and
enophthalmous
Superior orbital fissure
syndrome
55
Treatment

Rational for intervention:

Small defect with no clinical consequence
may not warrant the surgical intervention.

Large defect with handicapping symptoms
should be operated.
56
Method of reconstruction

Intra-sinus approach to
the orbital floor

External approach to
the internal orbital floor
57
Materials in orbital reconstruction

Autologous graft
Bone (cranial, rib, iliac)
Cartilage

Allogenic materials
Lyophilized dura

Alloplastic materials
Siliastic and proplast
implants
Teflon
hydroxyapatite
Titanium mish
58
Zygomatic complex fractures
59
Zygomatic Arches: Anatomy
Prominent process
called Zygomatic
process
Squamous portion of
temporal bone:


Projects anteriorly
Articulates with zygoma


Anatomy of Zygomatic Articulations
1) zygomatic Process

2) Condyle of mandible

3) Articular Tubercle

4) Coronoid process

5) Zygoma

Zygomatico-temporal Suture
Zygomatic bone complex

Anatomy
Star-shape like with four processes
 Frontal process
 Temporal process
 Buttress
 Orbital floor (Maxilla and GWSB)
Temporal fascia and muscle
Masseter muscle
63
Zygomatic complex and arch fracture
The malar bone represent a
strong bone on fragile
supports, and it is for this
reason that, though the
body of the bone is rarely
broken, the four
processes- frontal,
orbital, maxillary and
zygomatic are frequent
sites of fracture.
Zygomatic bone fractured as a
block near its principle three suture
lines and often displaces inwards to
a greater or lesser extent.
64
Occurrence
•As isolated fracture
•In combination with other middle third fracture
•With internal orbital fracture (blow out)

Observed in (>50%) of middle third fracture (in
developed countries due to assaults)

The zygomatic arch fracture can be isolated
in most of the cases
65
Zygomatic Fractures
Isolated Zygomatic Arches
Isolated Zygomatic Arch Fractures
Tripod Fracture
Common Projections
for Zygomatic Arches

SMV

Tangential: oblique inferosuperior

Modified Towne: AP Axial
SMV for Zygomatic Arches

Seated or supine

IOML parallel with IR

MSP perpendicular

If supine:
 Flex knees
 Elevate trunk for full
neck extension
 Relax abdomen

CR perp to IOML and
entering 1” posterior to
outer canthi
SMV Radiograph
for Zygomatic Arches

Zygomatic arches free
from overlying structures

No rotation as indicated
by symmetric arches w/o
foreshortening

Mandibular symphysis SI
frontal bone
SMV Radiograph and Diagrams
Tangential Projection for
Zygomatic arches

Seated or supine

IOML parallel with IR

MSP 15 degrees toward
side being examined

Tilt vertex 15 degrees
away from side being
examined

CR perp to IOML and
centered to arch at a point
1” posterior to outer
canthus
Tangential Radiograph
for Zygomatic arches

Zygomatic arch free
from overlying
structures

Zygomatic arch not
overexposed

Collimate tightly
Tangential Anatomy
Tangential Obliques
Modified Towne: AP Axial
for Zygomatic Arches

Seated or supine

MSP & OML
perpendicular

CR to enter glabella
approx 1” above nasion

OML: 30 caudad
IOML 37 caudad

Modified Towne Radiograph
for Zygomatic Arches

No overlap of
zygomatic arches by
mandible

No rotation as evident
by symmetric arches

Arches projected lateral
to mandibular rami
Modified Towne Anatomy
Signs and symptoms

Periorbital ecchymosis and edema

Flattening of the malar prominence

Flattening over the zygomatic arch

Pain and tenderness on palpation

Ecchymosis of the maxillary buccal sulcus

Deformity at the zygomatic buttress of the
maxilla

Deformity at the orbital margin
82









Trismus
Abnormal nerve sensibility
Epistaxis
Subconjunctival ecchymosis
Crepitation from air emphysema
Displacement of palpebral
fissure (pseudoptosis)
Unequal pupillary levels
Diplopia
enophthalmos
83
Clinical examination

Inspection

Palpation

Visual examination



Eye movement
Diplopia
Pupil reaction
84
Radiographical evaluation
Nothing is more valuable to the surgeon in
determining the extent of injury and the position
of the fragments-both before and after
operation- than a good skiagram (radiograph)
85

Occipitomental view
(Posterioanterior oblique)

(water’s view)
86

submentovertex
Recommended for isolated
zygomatic arch fracture
87
CT scan


Coronal sections
Axial sections
88
Classifications

Displacement
Rotation along the axis of FZ processes
Anterio-posterior displacement
Rotation along the prominence of the bone
Medio-lateral displacement

Extension of the fracture along processes
points of fractures

Combination with other injuries
89
Treatment
Timing:
 As early as possible unless there are ophthalmic, cranial
or medical complications

Preiorbital edema and ecchymosis obscure the fine
details of the fracture, intervention can be postponed but
not more than a week
Indications:
•Diplopia
•Restriction of mandibular movement
•Restoration of normal contour
•Restoration of normal skeletal protection for the eye
90
Treatment
The methods of treating a fractured malar bone
recommended by the various writers who have reported
cases include simple digital manipulation under genre real
anesthesia, external manipulation by means of a cow-horn
dental forceps grasping the edges of the bone, traction and
elevation by means of wire or heavy bone elevators passed
through small local external incisions, and elevation via
incision in the mucosa of the ginigival sulcus at the canine
fossa. Our technique, which has now been used
successfully in a number of cases, differs from those
mentioned.
91
Methods of reduction

Temporal approach (Gillies et al
1927)
Suitable for isolated
zygomatic fracture with
good stability afterwards
92
Methods of reduction

Percutaneous approach (malar hook,
Carroll-Girard bone screw)
Suitable for displaced zygomatic
fracture with high
Stability after reduction
93
Methods of reduction

Buccal sulcus
approach (Keen 1909)

Elevation from
eyebrow approach
(the same principle of Gillies
approach)
94
Open reduction and fixation

Transosseous wiring at
Frontozygomatic suture
 Infraorbial rim

Surgery:
•Lateral eyebrow incision
•Infraorbital approach
95
Open reduction and fixation

Rigid fixation using plate and screws at



Frontozygomatic suture
Infraorbial rim
Inferior buttress of the zygoma
Surgery:
•Lateral eyebrow incision
•Infraorbial approach
•Subciliary (blepharoplasty) incision
•Mid-lower lid incision
•Transconjunctival approach
96
Points of fixation:
Lateral
orbital rim
Buttress of
zygoma
Infraorbital
rim and
buttress 97
Other methods of fixation

Kirschener wire

Pin fixation

Antral pack
98
Zygomaticomaxillary fractures
Waters projection - Normal arch
Zygomatic fracture
Zygomatic arch fractures
Zygomatic arch fracture
3D- CT
3D-CT
Complications
Complication to zygomatic fracture
Closed mouth
1
Open mouth
2
Lé Fort fractures
LeFort Fracture 1




Le Fort I (“floating palate”)
Characterized by a horizontal fracture through
the maxillary sinuses
With separation of the entire palate and maxillary
alveolar processes.
This fracture type includes the lower nasal
septum and inferior aspect of the pterygoid
plates.
Le Fort Fracture 2



Le Fort II (“pyramidal”) is
characterized by an inverted
‘V’ type fracture through the
medial orbital and lateral
maxillary walls.
Through the nasal septum,
frontal process of the
maxilla, medial wall of the
orbit, inferior orbital rim,
superior, lateral, and
posterior walls of the
maxillary antrum, and
midportion of the pterygoid
plates.
This type of fracture can be
associated with posterior
displacement of the facial
bones resulting in a “dishface” deformity
Le Fort 3




Le Fort III ("craniofascial disjunction”) is
Characterized by separation of the entire viscerocranium
from the base of the skull.
Horizontal fracture through the orbits beginning near the
nasofrontal suture and extending posterior to involve the
nasal septum, medial and lateral orbital walls, zygomatic
arches, and base (superior aspect) of the pterygoid plates.
This type of fracture also may result in a “dish-face”
Lé Fort I
Lé Fort II
Le Fort 3 and mastication problem
Complications from upper midline
fractures






Mucocele
Leakage of CSF
Meningitis
Lacrimal problem
Telecantism
Anosmia
Mucocele
Penetration from mucocele
Increased intercanthal distance
CSF-leakage after upper midline
fracture
CSF leakage, Meningitis,
Optic nerve damage
CSF leakage from temporal bone
fracture
Fluid
Air
Lacrimal channel
Normal dacryocystography
Abnormal dacryocystography
Lacrimal problem
Name this fracture:
Le Fort 1
Name this fracture:
LEFORT 3
Name this fracture:
Structures connection
(structures in relation)






Orbit
Maxillary sinus
Nasal bone
Naso-orbital ethmoid
(NOE) complex
Zygomatic complex
Frontal bone and sinus
131
Le Fort’s fractures
Le Fort I (low level or
Guerian fracture)

Unilateral/ bilateral
Horizontal fracture
through the maxilla above
the level of the nasasl
floor and alveolar process

Piriform rims
Anterior maxilla
Zygomatic buttresses
Ptrygoid laminae




132
Signs and symptoms

Slight swelling of upper lip

Ecchymosis in upper lip sulcus

Hematoma intra-orally over zygoma and in palate

Disturbed occlusion

Mobility of teeth of the involved segment of maxilla

Combination of soft tissue laceration

Exposure of nares and the maxillary antra in case of gross injury

Impacted type of fracture is oftenly not mobile and teeth cusps
may be damaged

Cracked-pot percussion of upper teeth
133
Le Fort’s fractures

Le Fort II
(pyramidal or subzygomatic)
Separation of NF suture, medial
orbital walls (lacrimal bone),
inferior orbital floor and rim
(adjacent to infrorbital canal
and foramen), anterior maxilla
below zygomatic buttress and
ptrygoid laminae about halfway
up.
Separation of the block from the base of skull is completed
via the nasal septum and may involve the floor of the
134
anterior cranial fossa
LeFort’s fractures

LeFort III
(cranifacial dysjunction, high transverse,
suprazygomatic)
Separation of NF suture, medial
orbital walls (involve the depth of the
ethmoid bone and cribriform plate,
pass below optic foramen and cross
the inferior orbital fissur), inferior
orbital floor, lateral orbital wall, ZF
suture, zygomatic arch,
suprazygomatic to the root of
ptrygoid plate.
135
Signs and symptoms
although it is possible to distinguish between le fort II and III, the signs and
symptoms are almost similar











Gross edema of soft tissue
Bilateral circumorbital
ecchymosis
Bilateral subconjunctival
hemorrahge
Obvious deformity of the nose
Nasal bleeding and obstruction
CSF leak rhinorrhea
Dish-face deformity
Limitation of ocular movement
Possible diplopia and
enophthalmous
Retropostioning of the maxilla
with anterior open bite
Lengthening of the face










Difficulty in mouth opening
Mobility of the upper jaw
Occusional hematoma of the
palate
Cracked-pot sound on percussion
Step deformity at infra-orbiatal
margin
Anasthesia of midface
Nasal bone moves with mid-face
as a whole
Tenderness and sepration at FZ
suture
Tenderness and deformity of
zygomatic arch
Depression of occular level and
pseudoptosis
136
Bowerman classification of midface-fracture (1994)

Fracture not involving the occlusion

Central region






Nasal bone/ septum (lateral, anterior injuries)
Frontal process of the maxilla
Nasoethmoid
Fronto-orbito-nasal dislocation
Lateral region (zygomatic complex EX dento alveolar frcature
Fracture involving the occlusion

Dento alveolar

Subzygomatic:


Le Fort’s (I, II)
Supra zygomatic:

Le Fort III
137
These fractures may occur unilaterally or bilaterally, with separation
of maxillary midline and or extension to frontal or temporal bone
Prevalence of mid-face fractures
Fracture Type
Prevalence
Zygomaticomaxillary complex (tripod fracture)
LeFort
40 %
I
15 %
II
10 %
III
10 %
Zygomatic arch
10 %
Alveolar process of maxilla
5%
Smash fractures
5%
Other
5%
138
Diagnosis

Inspection
Extra-oral
(e.g. swelling, deformity, asymmetry
Leaks)
Intra-oral
(e.g. hematoma, occlusion)
 Palpation
Step deformity, criptation, cracked pot sound, mobility

Radiographical investigations
139
Radiographical examination
Plain radiograph

Occipitomental
(10 or 30 degree)

Water’s view
Suitable for isolated orbital fracture
Search line (Campbell’s line 1977)
140
Radiographical examination




Lateral skull view
OPG
Occlusal view of the maxilla
Perapical views of damaged
teeth
141
Radiographical examination


CT scan
3-D CT imaging


Coronal sections
Axial sections
1. Whenever intracranial damage and
frontal sinus are suspected
2. Extensive fracture that involves
nasoethmoid complex or orbital
region
3. Orbital trauma to evaluate the
degree of orbital injury and
enophthalmos
142
143
Indications for treatment

Physical signs of a fracture of the maxilla.

Evidence of a fractured maxilla on imaging.

Disruption of the occlusion of the teeth.

Displacement of the maxilla.

Post traumatic facial deformity.
144
Indications for treatment

Fractured or displaced teeth.

Cerebrospinal fluid leak.

Abnormal eye movement or restriction of eye movement.

Occlusion of the nasolacrimal duct.

Sensory or motor nerve deficit.

Other evidence of loss of function
145
Aims of treatment

Relieve pain

Restore function.

Restore bone anatomy.

Prevent infection

Restore the dental occlusion

Restore jaw movement at the earliest possible stage

Restore normal nerve function
146
Factors affecting the risk

Association with multiple injuries.

Presence of uncontrolled haemorrhage

Impairment of the airway.

Presence of bone comminution

Association with a dural tear.

Association with a base of skull fracture.
147
Factors affecting the risk

Presence of a pre-existing dentofacial deformity.

Time elapsed since the injury.

Presence of a medical or surgical factor which would delay
general anesthesia

Presence of any factor which would delay healing. (eg
nutritional deficiency or alcoholism)

Stage of dental development (deciduous, mixed or
permanent dentition)
148
Factors affecting the risk

Presence of fractured teeth.

Total absence of teeth (edentulous)

Inability of the patient to co-operate with treatment.

Association with fractures of the mandible especially
bilateral fractures of the condyles.
149
Principles of treatment
Closed reduction may be appropriate in cases

Simple uncomplicated fractures

Complex or comminuted fractures

Medical or surgical contraindications to open
reduction

Maxillary fractures in children
150
Open reduction may be appropriate where

Immediate or early jaw function is desirable

Difficulty is encountered in reducing the
fracture by a closed method

The fracture is unstable
151
Definitive treatment

Reduction
Manual manipulation
Use of dis-impaction forceps
152
Fixation and immobilization
Extraoral fixation
Craniomandibular fixation
Box-frame (pin fixation)
Halo-frame
Plaster of paries headcap
Craniomaxillary fixation
Supra-orbital pins
Zygomatic pins
Halo-frame
153
Immobilization within the tissue
Direct fixation




Transosseous wiring at
fracture sites
Frontozygomatic sutures
Infrorbital margin
Midline of the palate
154
Immobilization within the tissue
Internal-wire suspension
Circumzygomatico-mandibular
Infraorbital border-mandibular
Frontomandibular
Pyriform fossa-mandibular
155
Immobilization within the tissue
Support via the maxillary sinus by filling
materials




Ribbon gauze
Balloon
Folly catheter
Polyethylene material
156
Length of the hospital stay will depend on a
number of factors including:

Presence of other injuries

Age and medical status of the patient

Severity of the injury

Technique employed in the reduction and fixation of
the fracture

Presence or absence of medical or surgical
complications

Social circumstances of the patient
157
Maxillofacial Trauma
Mandibular Fractures
Mandible is embryologically a membrane bent bone although,
resembles physically long bone it has two articular cartilages
with two nutrient arteries
158
Mandible in trauma

Mandibular fracture is more common than middle third
fracture (anatomical factor)

It could be observed either alone or in combination with
other facial fractures

Minor mandibular fracture may be associated with head
injury owing to the cranio-mandibular articulation

Mandibular fracture may compromise the patency of the
airway in particular with loss of consciousness

Fracture of mandible occurred with frontal impact force as
low as 425 lb (190 Kg) {Condylar fracture}
159

Fracture of condyle regarded as a safety mechanism to the
patient

Frontal force of 800-900 lb (350-400 Kg) is required to cause
symphesial fracture

Mandible was more sensitive to lateral impact than frontal
one
Frontal impact is substantially cushioned by opening and
retrusion of the jaw
(Nahum 1975)


Long canine tooth and partially erupted wisdoms represent
line of relatively weakness
160
Anatomical considerations
Attached muscles:
 Masseter
 Temporalis
 Medial and lateral
pterygoid
 Mylohyoid
 Geniohyoid and
genioglosus
 anterior belly of
digastrics
161
Blood supply


Endosteal supply via the ID artery and vein
Periosteal supply, important in aging due to
diminishes and disappearance of alveolar artery
Nerve

Damage of inferior dental nerve
Facial palsy by direct trauma to ramus
Damage of facial nerve in temporal bone fracture

Damage to mandibular division of facial nerve


162
Factors influenced site of fracture and
displacement

Anatomy of the mandible
and attached muscle
(canine & wisdoms)

Weakening areas of
mandible (resorption and
pathologyl)

Direction of force of the
blow

Age of the patient
163
Types of fracture

Simple



Greenstick fracture (rare, exclusively in children)
Fracture with no displacement (Linear)
Fracture with minimal displacement

Displaced fracture

Comminuted fracture
Extensive breakage with possible bone and soft tissue loss

Compound fracture
Severe and tooth bearing area fractures

Pathological fracture
(osteomyelities, neoplasm and generalized skeletal disease)
164
Sites of fractures

Condyle fracture


Intracapsular fracture
Extracapsular fracture


High condyle neck fracture
Low condylar fracture

Angle/ ramus fracture (body
fracture)

Canine region (parasymphesial
fracture)

Midline fracture (symphesis
fracture)
Coronoid fracture (rare)

165
Incidence of mandibular fractures

Body fractures 33.6%

Subcondylar fracture 33.4%

Fractures at the angle 17.4%

Alveolar fractures 6.7%

Ramus fractures 5.4%

Midline fractures 2.9%

Fracture of coronoid process 1.3%
Oikarinen & Malmstrom 1969
166
Favourable or unfavourable

They can be vertically or horizontally in direction

They are influenced by the medial pterygoidmasseter “sling”



If the vertical direction of the fracture favours the
unopposed action of medial pterygoid muscle, the
posterior fragment will be pulled lingually
If the horizontal direction of the fracture favours the
unopposed action of messeter and pterygoid muscles in
upward direction, the posterior fragment will be pulled
lingually
Favourable fracture line makes the reduced
fragment easier to stabilize
167
Effects of muscles on displacement

Transverse midline fracture (symphesial) stabilizes
by the action of mylohyoid and geniohyoid

Oblique fracture (parasymphesial) tends to overlap
under the influence of muscles action

Bilateral parasymphesial fracture results in
backward displacement associated with loss of
tongue control when the level of consciousness is
depressed
168
Condylar fractures
The most common mandibular fracture


Unilateral or bilateral
Intracapsular or extracapsular

Antero-medial displacement is common
but it may remain
angulated with the ramus

Dislocation of the glenoid fossa and
fracture of petrous temporal bone which
is very rare
169
Condylar fractures
Sign and symptoms

Swelling, pain, tenderness and restriction of movement

Deviation of mandible towards the side of fracture

Gagging of occlussion (premature contact on the posterior teeth)
with bilateral condylar displaced or over-riding fractures

Displacement of mandible toward the affected side

Anterior open bite on opposite side of fracture

Laceration of EAM****

Retroauricular ecchymosis****

Cerebrospinal leak and otorrhea in association with skull base
fracture
170
Condylar fractures
Sequlae of TMJ injury

Artheritic changes

Haemartherosis, fibrosis and aknylosis

Meniscal damage and detachment

TMD

Staph infection with condylar backward displacement and
external auditory meatus injury

Meningitis with petrous temporal bone fracture and
intracranial involvement
171
Coronoid process fracture:

Rare fracture caused by direct trauma to ramus
and results from reflux contraction of temporalis

Can be seen following operation of large ramus
cyst

Elicit tenderness over the anterior part of ramus

Development of tell-tale haematoma
172
Fracture of the ramus:

Type I Single fracture
Mimics low condylar fracture that runs below
the sigmoid notch

Type II comminuted fracture
Common in missile injuries and appears to be
with little displacement due to effects of
messeter and medial pterygoid muscles
173
Fracture of the angle and body

Pain, tenderness and trismus

Extra-oral swelling at the angle with obvious
deformity

Step deformity behind the molar teeth

Movement and crepitus at the fracture site

Derangement of occlussion

Intra-oral buccal and lingula heamatoma

Involvement of IDN

Gingival tear if fracture in dentated area

Tooth involvement and possible longitudinal
split fracture
174
Midline fracture

The most common missed fracture (always
fine crack)

Can be symphesial or parasymphesial
fracture

Commonly associated with one or both
condyles fracture

Unilateral fracture leads to over-riding of
the fragments and bilateral may contribute
in loss of voluntery tongue control

Long canine tooth represent a weak area
and contributes to parasymphesial fracture

Rarely runs across mental foramen
175
Midline fracture
Signs and symptoms






Pain and tenderness
Swelling and odemea
Development of step deformity
Mental anesthesia
Heamatoma in the floor of mouth and buccal mucosa
Soft tissue injury of the chin and lower lip
If associated with condylar fractures





Absence of condyle movement on the contrlateral side
Deviation of mandible
Anterior open bite
Gagging of oclussion
Limitation of mouth opening
176
Clinical assessment and diagnosis

History of trauma
(traumatized patients with possible head injury) and facial injuries

Clinical Examination
▶ Extroral
Inspection (assessment of asymmetery, swelling, ecchymosis, laceration and cut
wounds)
Palpation for eliction of tenderness, pain, step deformity and malfunction
▶ Intra- and paraoral
bleeding, heamatoma, gingival tear, gagging of occlussion and
step deformity and sensory and motor deficiency

Radiographs
177
Radiographs

Plain radiograph








OPG
Lateral oblique
PA mandible
AP mandible (reverse
Townes)
Lower occlusal
CT scan
3-D CT imaging
MRI
178
Principles of treatment
similar to elsewhere fractures in the body

Reduction of fragments in good position

Immobilization until bony union occurs
These are achieved by:


Close reduction and immobilization
Open reduction and rigid fixation
Other objective of mandible fracture treatment:

Control of bleeding

Control of infection
179
Definitive treatment
Soft tissue repair




Debridment
Irrigation with saline and antibiotics
Closure in layers
Dressing
Reduction and fixation of the jaw
▶ Close reduction and IMF (traditional method by means of
manipulation)
▶ Open reduction and semi-rigid fixation (using inter-ossous
wirings)
▶ Open reduction and rigid fixation (using bone palates
osteosynthesis)
Objective:
Restoration of functional alignment of the bone fragments in
anatomically precise position utilizing the present teeth for
guidance
180
Close reduction

Arch bars




Jelenko
Erich pattern
German silver notched
Cap splints
▶ IMF prior to rigid fixation
▶ For the purpose of close
reduction
181
Close reduction
Bonded brackets
IMF screws
Dental wiring:





Direct wiring
Eyelet wiring
Local anesthesia or
sedation
Minimal displacement
IMF for 6 weeks
Treatment can be performed
under GA or LA and when
surgery is contraindicated
182
Fracture mandible in children




Close reduction
Open reduction and
fixation
Plating at the inferior
border
Resorpable plates
183
Gunning’s splint




Old modality
Edentulous patient
Rigid fixation is not
possible
To establish the
occlusion
184
Open reduction and fixation

Intraoral approach
Extraoral approach
▶ Submandibular
approach

185
Rigid fixation




Intraossous wiring
Plates and screws
Kirchener wire
Lag screws
186
Reconstruction palate
Severe trauma
Loss of part of the bone
187
Condylar fractures
Intraoral approach
Ramus incision


Extraoral approach
Preauricular approach
Retromandibular approach
188
IMF

Transosseous wiring

Circumferential wiring

External pin fixation

Bone clamps

Trans-fixation with Kirschner wires
189
Osteosynthesis

Non-compression small plates

Compression plates

Miniplates

Lag screws

Resorbable plates and screws
190
Teeth in the fracture line

The fracture is compound into the mouth

The tooth may be damaged or lose its blood
supply

The tooth may be affected by some
preexisting pathology
191
Management of teeth retained in fracture line






Good quality intra-oral periapical radiograph
Insinuation of appropriate systemic antibiotic therapy
Splinting of tooth if mobile
Endodontic therapy if pulp is exposed
Immediate extraction if fracture becomes infected
Follow up for 1 year and endodontic therapy if there
is a loss of vitality
192
Absolute indications





Longitudinal fracture
Dislocation or subluxation from socket
Presence of periapical infection
Infected fracture line
Acute pericoronitis
Relative indications




Functional tooth that would be removed
Advanced caries or periodontal diseases
Doubtful tooth which would be added to existing denture
Tooth in untreated fracture presenting more than 3 days
after injury
193
Fracture of temporal bone
Classifications
1.
2.
3.
Longitudinal fractures
Transverse fractures
Mixed fractures
Longitudinal fractures




80% of Temporal Bone
Fractures
Lateral Forces along
the petrosquamous
suture line
15-20% Facial Nerve
involvement
EAC laceration
Transverse fractures





20% of Temporal
Bone Fractures
Forces in the
Antero-Posterior
direction
Inner ear injury
50% Facial Nerve
Involvement
EAC intact
Physical Examination


Tuning Fork exam
Pneumatic Otoscopy
Imaging



HRCT
MRI
Angiography/ MRA
symptoms




Hearing Loss & tinnitus
Dizziness
CSF Otorrhea and
Rhinorrhea
Facial Nerve Injuries
Hearing loss



Formal Audiometry vs. Tuning Fork
71% of patients with Temporal Bone Trauma
have hearing loss
TM Perforations

CHL > 40db suspicion for ossicular discontinuity
Hearing loss
Longitudinal Fractures



Conductive or mixed hearing
loss
80% of CHL resolve
spontaneously
Transverse Fractures


Sensorineural hearing loss
Less likely to improve
Dizziness


Otic capsule fracture, labyrinthine concussion,
Perilymphatic Fistula
Perilymphatic Fistulas



Fluctuating dizziness and/or hearing loss
Tulio’s Phenomenon
Management


40% spontaneously close
Surgical management
Dizziness

BPPV




Acute, latent, and
fatigable vertigo
Can occur any time
following injury
Dix Hallpike
Epley Maneuver
CSF Otorrhea and Rhinorrhea



Temporal bone Fractures are the most
common cause of CSF Otorrhea
Beta-2-transferrin
HRCT
CSF Otorrhea and Rhinorrhea

Management

Conservative therapy



Lie in bed with Head elevated 30-45°
Antibiotics
Surgery
CSF Otorrhea and Rhinorrhea
Surgical Management

Surgical approach





Status of hearing
Meningocele/encephalocele
Fistula location
Transmastoid
Middle Cranial Fossa
Facial Nerve Injuries

Evaluation




Previous status
Time
Onset and progression
Complete vs. Incomplete
House Brackman grading system
I Normal Normal facial function
II Mild
Slight synkinesis/weakness
IIIModerate Complete eye closure, noticeable
synkinesis, slight forehead movement
IVModerately Severe
Incomplete eye closure,
symmetry at rest, no forehead movement
V Severe Assymetry at rest, barely noticeable
motion
VITotal
No movement
Electrophysiologic Testing



NET
MST
ENoG
Nerve Excitability Test
Maximal Stimulation Test

>3.5mA difference suggests a poor prognosis
for return of facial function
Electroneuronography


Most accurate, qualitative measurement
Reduction of >90% amplitude correlates with
a poor prognosis for spontaneous recovery
Electromyography


Limited use until 10-14 days
Polyphasic potentials= Good
Facial Nerve Injuries

Decision to treat is primarily based on
whether there is complete vs. incomplete
paralysis
Treatment


Conservative treatment candidates
Surgical candidates
Conservative Treatment Candidates

Chang and Cass



Normal Facial Function regardless of progression
Incomplete paralysis and no progression to
complete paralysis
Less than 95% degeneration by ENoG
Surgical Candidates

Critical Prognostic factors



Immediate vs. Delayed
Complete vs. Incomplete paralysis
ENoG criteria
Algorithm for Facial Nerve Injury
Surgical Approach


Suspect location of neural injury
Presence or absence of hearing
Surgical Approach

Lateral to the geniculate ganglion


transmastoid
Medial to the Geniculate Ganglion

No useful hearing


Transmastoid-translabyrinthine
Intact hearing


Transmastoid-trans-epitympanic
Middle Cranial Fossa
Surgical findings

Nerve repair



Direct anastomosis
Nerve graft
Decompression
Case Report

32 yr old fisherman was wading




Minding his own business
Hit in head by a flying fish
Immediate profound vertigo, hearing loss
CT scan revealed longitudinal Temp bone
fracture
Types of Weapons


Low velocity – knives, ice picks, glass
High velocity – handguns, shotguns, shrapnel
Guns
Ballistics
Ballistics
Management of Penetrating
Neck Trauma
Ballistics
Anatomy
Anatomy
Incision for Neck Exploration:
Incisions for Neck Exploration:
Incidence and Mortality
Initial Management
Signs of Injury:
Signs of Injury:
Management of the Stable Patient:
The Old Standard:
The Old Standard:




Based on wartime experiences
Fogelman et al (1956) showed that
immediate neck exploration led to better
outcomes in study group for vascular injuries.
Led to rate of negative neck explorations in >
50%
Arteriogram slowly began to gain acceptance
as screening tool before exploration,
especially for zone 1 and 3 injuries (hard to
detect on physical).
Cervical Spine Stenosis

Mechanism/Etiology



Assessment
Diagnostic Tests




Narrowing of spinal canal
X-rays
MRI
CAT scan
Treatment


Non-surgical
Surgical
Cervical Fractures

Types of Fractures

Atlanto-axial

Mechanism


Hyperextension
Children >adults
Cervical Fractures
Anterior arch

Types of Fractures


Atlanto-axial
Jefferson

Mechanism


Compressive Force
Burst Fracture
Anterior arch
Posterior arch
Cervical Fractures

Types of Fractures



Atlanto-axial
Jefferson
Hangman’s fracture

Mechanism



Hyperextension/compre
ssion force
Fracture to C2
Pedicle C2 with anterior
slippage of C2/C3
Cervical Fractures

Types of Fractures




Atlanto-axial
Jefferson
Hangman’s fracture
Burst


AKA Compression Fx
Mechanism



Flexion
Vertebral body
Neurology
Cervical Fractures

Types of Fractures





Atlanto-axial
Jefferson
Hangman’s fracture
Burst
Clay-Shovelers


Spinous process of C6
or C7
Mechanism

Result of rotations of
trunk relative to neck
Cervical Fractures

Types of Fractures






Atlanto-axial
Jefferson
Hangman’s fracture
Burst
Clay-Shovelers
Tear Drop

Violent extension force
Cervical Fractures

Assessment





History/Mechanism
Inspection
Palpation
Functional Test
Neurological Exam
Questions and Answers