MEMENTO MORI
MAXILLO-FACIAL TRAUMA
R.Drummond
October 24, 2002
preceptor: Carol Holmen
Overview
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General approach to facial trauma
Epidemiology
anatomy
diagnostic imaging
specific conditions
diagnosis of facial trauma as a
presentation of abuse
Conclusions
General Comments
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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:
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1)Water’s view
2)Lateral view
3)Caldwell view
4)Towne’s view
Question2 : Most associated injuries in cases of
maxillofacial trauma are to the:
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1)brain
2)cervical spine
3)chest
4)abdomen
Question 3: Open bite may be secondary to all
except:
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1)LeFort 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
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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
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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
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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
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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
10litres GCS 14
primary survey gurgling resps with considerable
blood in mouth gaping wounds across forehead
jaw is mangled with evident deformity
Patient 3
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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
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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
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Most common causes:
MVA’s, falls, assault
community: nose and mandible
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urban:
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:MVA’s and Sports
midface, zygoma
penetrating and assault
more than 60% have associated
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other injuries
MVA
Epidemiology of MaxilloFacial Injuries at Trauma
Hospitals in Ontario, Canada between 1992 and
1997
The Journal Of Trauma, September 2000... Hogg et al
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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,
MacKenzie et al
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Retrospective cohort study of adults 18 - 25
265 pts with LeFort 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
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Obvious sequelae:
Diplopia 56% Zygomatic fractures
23% LeFort fractures
20 -31% midface fractures difficulties mastication
35% Anasomia in LeFort 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
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“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
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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
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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
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All patients with significant facial injuries
must be presumed to have cervical spine
injury until proved otherwise
History
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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
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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
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Allergies
Tetanus status
Anatomy
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Vertical buttresses: nasal, frontal, and zygomatic
maxillary give vertical stability
zygomatic temporal buttresses horizontal support
Three Zones of Facial Anatomy
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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
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Standard Four Views
Waters
Caldwell
Lateral
Submentovertex
Occlusal views
Panorex
Waters View
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Most valuable
prone.... Clear c-spine
draw four lines should be parallel and smooth
WATERS VIEW
WATERS VIEW
WATERS VIEW PARALLEL LINES
Caldwell View
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Supplements Waters view
superior orbital rim
sinuses
orbital region
can see teardrop sign
open bomb bay door sign
CALDWELL VIEW
CALDWELL VIEW
Lateral View
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Frontal Sinus
maxillary sinus
occasionally pterygoid plate
LATERAL VIEW
Submentovertex view
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“Jughandle” view
Main value is to see zygomatic arch
SMV VIEW
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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 slo-pitch
baseball game hit in forehead by baseball bat
large laceration with swelling forehead 3 min
LOC
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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
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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
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Skull films useful
if xray positive Ctscan
Management
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CNS or ENT consult
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??Antibiotics
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if yes, first generation cephalosporin
clavulin or septra
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anterior wall elevation for cosmesis
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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
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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
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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
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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
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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
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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
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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
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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
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Complicated by edema, blood, temporary
neuromuscular injury,change in orbital shape,
third nerve palsy
entrapped EOM does not resolve
forced duction test
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Enophthalmosis :retraction of eye into socket
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investigations
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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
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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, McMann et al., American Journal of Emergency Medicine
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100 Blowout Fractures
59 pure blowout fractures
age 8 to 75
falls, aggression, and sports
periorbital ecchymoses, diplopia, hypoesthesia in
V2 intraorbital emphysema
plain xrays 13/26 false negative
only 5 true positives
CT 51/59 true positives
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Implants 35/55 cases
lyophilized bovine before 1996
controversy in 1971 and 1974
most enophthalmosis and diplopia spontaneously resolve
orbital floor repair dangerous
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current recommendations:
surgery if diplopia from entrapment not gone 2 weeks
enophthalmosis greater than 2 mm
orbital floor greater than 50% blown out
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(unacceptable cosmetic results)
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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
MogenDavid 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 #
3D RECONSTRUCTION # ZYGOMATIC ARCH
Cause
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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
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Does it hurt to open your mouth?
Is your lower lid, cheek, teeth numb?
MASSETER MUSCLE
Findings
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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
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Single Waters view
submentovertex view
Ctscan definitive
Management
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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
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Huge amounts of energy
high association with other injuries
classification system
LeFort I,II, 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?
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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
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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
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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
LeFort 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
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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:
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How is your bite?
Does your jaw hurt?Where?
Is your lower lip and or chin numb?
Investigations
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Tongue Depressor test
plain films esp panorex usually adequate
Management
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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
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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
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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
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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
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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 MaxilloFacial Fractures
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“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
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ICP Monitor and ventriculostomies: Ancef 1 gm iv
prior to insertion then q8 x3 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
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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 “
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1% of pediatric population
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Age 0 -5.... 17%
6 - 14... 57%
15 -17.... 26%
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75 % of fatalities happen to children under five years of age
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History in family background
findings in child’s behaviour
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common facial fractures:
dental fractures, oral bruises, oral lacerations
mandibular or maxillary fractures
oral burns, avulsed teeth
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dental x-rays multiple healed fractures
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SPOUSAL ASSAULT
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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)
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Lacerations head and face
hair loss, fractured teeth
fractured jaw, isolated facial fractures
bite marks, black eyes
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injuries without explanation
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Abuse of the Elderly
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Be aware of neglect
dental caries, cheilitis poor hygiene, unkempt
appearance
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perpetrator often direct care-giver
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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:
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1)Water’s view
Question2 : Most associated injuries in cases of
maxillofacial trauma are to the:
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1)brain
Question 3: Open bite may be secondary to all
except:
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4)NEO fracture
Question 4: All of the following are true about
children with maxillo facial trauma except
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1)greater risk of lower cervical
spine injury
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TAKE HOME POINTS
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Huge amount of force to injure face: watch for other injuries
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MVA’s major cause of injury: strategies to prevent injuries
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Major Long Term Sequelae both physical and personal
TAKE HOME POINTS
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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
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Waters view overall most useful view mid face
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Panorex most useful view for mandible
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CTScan most useful modality for Orbits and
Maxilla
TAKE HOME POINTS
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Frontal Bone Fracture takes lots of force check
intracranial and eye status
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NOE fractures orbital fractures by definition
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Nasal fractures - check for and drain septal hematomas
TAKE HOME POINTS
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Orbital injury urgent referral needs Ctscan
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Zygoma fractures arch common, tripod serious
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LeFort fractures are rarely classic in presentation
TAKE HOME POINTS
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Fractured jaw chin points to side, dislocated jaw
points away
Immediate replacement for avulsed teeth
Prophylactic antibiotics not necessary facial
fractures
TAKE HOME POINTS
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Think of growth retardation in facial fractures kids
If you see facial injuries think abuse in children,
women, elderly