Maxillofacial trauma

Exam

Face

• Numbness
  • Check supraorbital, infraorbital, and mental nerves
• Assess Le Fort by rocking hard palate w/ one hand while stabilizing forehead w/ other

Eye

• Exam
  • Bird's eye view for exophthalmos w/ retrobulbar hematoma
  • Worm's view for endophthalmos (blow-out fx) or malar prominence flattening (zygoma fx)
• Acuity
• Diplopia
  • Binocular diplopia suggests entrapment of EOM
  • Monocular diplopia suggets lens dislocation
• Extraocular motion
  • Limitation on upward gaze occurs w/ fx of inf and medial orbital wall
• Pupil
  • Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test)
• Pressure (only if r/o globe rupture)
  • Check in pts w/ exophthalmos, afferent nerve defect or e/o retrobulbar hematoma
• Fat through wound = septal perforation
• Raccoon eyes

Nose

• Crepitus over any facial sinus suggests sinus fx
• Septal hematoma
• Make sure simple nasal fx isn't a complex naso-orbito-ethmoid injury

Ears

• Auricular hematoma
• CSF leak
• Hemotympanum
• Battle Sign

Oral

• Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury
• Mandible Fx
  • Place finger in auditory canal while pt opens and closes jaw to detect condyle fx
  • Tongue blade test
    • 95% Sn for no fx if can bite down hard enough to break it when twisted by examiner
  • Jaw deviation due to mandible dislocation or condyle fx
    • Chin will point away from dislocation, towards a fracture
• Malocclusion occurs in mandible, zygomatic, and Le Fort fx
• Lacerations and mucosal ecchymosis suggests mandible fx

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 fractured)
  • Need neurosurg or ENT for posterior wall fx since many need surgery and IV abx
• 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 w/ ENT in 7-10 day
• 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

Fracture Types

Frontal Bone

• Requires high-energy
  • Must rule-out TBI, additional fx, and cervical spine injury
• Assess sinus involvement:
  • Crepitus
  • Laceration over fracture site is typical
• Imaging
  • Head CT indicated if suspect fracture
    • Assess anterior and posterior tables
      • Through and through fx require sx to prevent pneumocephalus, CSF leak, infection
• Management
  • Sinus involvement?
    • If yes then give 1st gen cephalosporin or amoxicillin clavulanate
  • Isolated anterior table fx?
    • D/C w/ facial surgeon f/u
  • Depresed fx?
    • Admit for IV abx and operative repair

Orbital

• See Orbital Fracture

Zygoma

• Must distinguish zygomatic arch fx from zygomaticomaxillary (tripod) fx
  • Tripod fx = fx of zygomatic arch, lat and inf orbital rims, lat wall of maxillary sinus
• Exam
  • Flattening of malar eminence
  • Eye findings
    • Eye may appear to tilt (pulling of lateral canthus)
    • Subconjunctival hemorrhage
  • Trismus (masseter spasm or impingement of temporalis muscle or coronoid process)
    • Palpate posterior surface of arch for tenderness/loss of space compared to other side
• Management
  • Facial CT
• Disposition
  • Isolated zygomatic arch fx: discharge
  • Tripod fx w/ loss of vision or displacement: admit for IV abx and sx

Midface

Classification

• • Le Fort I
    • Transverse fx separating body of maxilla from pterygoid plate and nasal septum
    • Only hard palate and teeth move (when rock hard palate while stabilizing forehead)
  • Le Fort II
    • Pyramidal fx through central maxilla and hard palate
    • Movement of hard palate and nose occurs, but not the eyes
  • Le Fort III
    • Craniofacial dysjunction (fx through frontozygomatic sutures, orbit, nose, ethmoids)
    • Entire face shifts w/ globes held in place only by optic nerve)

Management

• CT Face
• Control hemorrhage w/ nasal and oral packing if needed
• Admit for IV abx and sx

Mandible

• See Mandible Fracture

Pediatric Considerations

• Cricothyrotomy is contraindicated in pts <8yr old
• Maxillary sinuses do not develop until 6 yr old (reduces midfacial fx)
• Pediatric orbital floor is more pliable, more likely to lead to entrapment
• Mandible fx requires prompt referral (1-2d) due to rapid bone remodeling

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

• Mandible Fracture
• Orbital Blowout Fracture
• Head Trauma (Adult)
• Head Trauma (Peds)

Source

Tintinalli's.