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

1. Le Fort I
   1. Transverse fx separating body of maxilla from pterygoid plate and nasal septum
   2. Only hard palate and teeth move (when rock hard palate while stabilizing forehead)
2. Le Fort II
   1. Pyramidal fx through central maxilla and hard palate
   2. Movement of hard palate and nose occurs, but not the eyes
3. Le Fort III
   1. Craniofacial dysjunction (fx through frontozygomatic sutures, orbit, nose, ethmoids)
   2. 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