Maxillofacial trauma: Difference between revisions
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==Diagnosis==
==Diagnosis==
*Always ask about vision
*Evaluate for:
**Facial numbness
**Misalignment of teeth
**Diploplia (monocular vs binocular)


*Anesthesia of upper lip and/or maxillary teeth may be 2/2 infraorbital nerve injury from orbital blowout or orbital rim fx


ALWAYS ASK ABOUT VISION.
*Physical Exam
**Jaw deviation - chin will point away from dislocation and towards a fracture
**Best way to palpate the mandibular condyles is to place a finger in the external auditory canal and press down while pt opens and closes mouth.


facial numbness, misalignment o teeth, and diploplia (monocular vs binocular)
Imaging
 
*Suspect midface fx > facial CT
anesthesia of upper lip and/or maxillary teethmay be due to infraorbital nerve injury fromorbital blowout or orbital rimFx.
*Suspect orbital floor fx > orbital CT
 
*Suspect mandibular Fx
**Mandibular series
 
**Body fx > oblique view
Exam (finer points): jaw deviation-the chin will point away from a dislocation and towards a fracture.
**Angle/symphysis fx > PA view
 
**Condyle fx > AP axial (Towne's) view
The best way to palpate the mandibular condyles is to place a finger in the external auditory canal and press down while pt opens and closes mouth.
*Plain Films
 
**Water's view
***Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
 
**Bucket handle view
Radiology-
***zygomatic arches
 
If high suspicion of midface Fx then o directly to facial CT. Orbital floor Fx can be seen w/ orbital CT.
 
Water's view- can see orbital rims, floors, zygmatic arch, as well as maxillary sinus and maxilla.
 
Bucket handle view to examine zygomatic arches.
 
Panorex or mandibular series for mndibular Fx. Fractures throughthe mandibular body are best seen on the oblique view. Fractures through theangle and symphysis are best seen on th PA view. Fx through themandibular condyles are best seen through the AP axial(Towne's) view
 


==DDx==
==DDx==
 
*Frontal sinus fractures
 
**If ant wall Fx need CT to evaluate posterior wall (75% have both walls Fx)
Frontal sinus fractures: ant wall isthick and the posterior wall is thin. Only 18% of frontal sinus fractures are anterior wall only. If ant wall Fx-need CT t evaluate posterior wall. (75% have both walls Fx). Need neurosurg or ENT for post wall since many need surgery and IVABx.
**Need neurosurg or ENT for posterior wall fx since many need surgery and IVABx
 
*Naso-ethmoid fractures
**Diffuse tearing and increased intercanthal distance are suggestive
**Intranasal palpation w/ hemostat while palpating along bony rim for crepitus
**Complications include:
***Lacrimal disruption
***Medial canthal ligament rupture
***Dural tears
***Intracranial injury seen in up to 70%
*Nasal Fx
**Clincal diagnosis (does NOT require xrays)
**Drain septal hematomas and f/u with ENT in 7-10 days
*Zygomatic arch fracture
**Unlikely isolated
*Tripod Fracture
**Fx through:
***1. Inf orbital rim
***2. lateral orbital wall
***3. Fx/dislocation of zygomatic arch
**Must r/o associated ocular injuries
**Usually requires admission and surgical repair
   
   
Naso-ethmoid fractures- diffuse tearing and increased intercanthal distance are suggestive. intranasal palpation w/ hemostat while palpating along bonyrim for crepitus useful.
complications include lacrimal disruption, medial cathal ligament rupture, and dural tears. intracranial injury seen in up to 70%. can develop malignant periorbital emphysema and blinndness. cover w/ABx and have pt see maxillofacial surgeon.
Nasal Fx-clincal diagnosis (no xrays) drain septal hematomas and f/u with ENTin 7-10 days
Zygomatic arch fractures- unlikely isolated
Tripod Fractures-
Fx through 1)inf orbital rim, 2) lateral orbital wall, 3) fx/disocation of zygomatic arch.
-must rule out associated ocular injuries. usually requires admission and surgical repair.
==Disposition==
==Disposition==
 
*Bedside consult is necessary for:
 
#Decreased vision
bedside consult is necessary for:
#Tripod fractures
 
#Lefort fractures
decreased vision, tripod fractures, Lefort fractures, openmandibular fractures, frontal sinus fractures with intracranial involvement, NEO injuries.
#Open mandibular fractures
 
#Frontal sinus fractures with intracranial involvement


==See Also==
==See Also==


Trauma: Mandible Fx
Trauma: Mandible Fx
Optho: Orbital Blowout Fx
Optho: Orbital Blowout Fx


[[Category:Trauma]]
[[Category:Trauma]]

Revision as of 23:34, 2 April 2011

Diagnosis

  • Always ask about vision
  • Evaluate for:
    • Facial numbness
    • Misalignment of teeth
    • Diploplia (monocular vs binocular)
  • Anesthesia of upper lip and/or maxillary teeth may be 2/2 infraorbital nerve injury from orbital blowout or orbital rim fx
  • Physical Exam
    • Jaw deviation - chin will point away from dislocation and towards a fracture
    • Best way to palpate the mandibular condyles is to place a finger in the external auditory canal and press down while pt opens and closes mouth.

Imaging

  • Suspect midface fx > facial CT
  • Suspect orbital floor fx > orbital CT
  • Suspect mandibular Fx
    • Mandibular series
    • Body fx > oblique view
    • Angle/symphysis fx > PA view
    • Condyle fx > AP axial (Towne's) view
  • Plain Films
    • Water's view
      • Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
    • Bucket handle view
      • zygomatic arches

DDx

  • Frontal sinus fractures
    • If ant wall Fx need CT to evaluate posterior wall (75% have both walls Fx)
    • Need neurosurg or ENT for posterior wall fx since many need surgery and IVABx
  • Naso-ethmoid fractures
    • Diffuse tearing and increased intercanthal distance are suggestive
    • Intranasal palpation w/ hemostat while palpating along bony rim for crepitus
    • Complications include:
      • Lacrimal disruption
      • Medial canthal ligament rupture
      • Dural tears
      • Intracranial injury seen in up to 70%
  • Nasal Fx
    • Clincal diagnosis (does NOT require xrays)
    • Drain septal hematomas and f/u with ENT in 7-10 days
  • Zygomatic arch fracture
    • Unlikely isolated
  • Tripod Fracture
    • Fx through:
      • 1. Inf orbital rim
      • 2. lateral orbital wall
      • 3. Fx/dislocation of zygomatic arch
    • Must r/o associated ocular injuries
    • Usually requires admission and surgical repair

Disposition

  • Bedside consult is necessary for:
  1. Decreased vision
  2. Tripod fractures
  3. Lefort fractures
  4. Open mandibular fractures
  5. Frontal sinus fractures with intracranial involvement

See Also

Trauma: Mandible Fx Optho: Orbital Blowout Fx

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