Maxillofacial trauma: Difference between revisions
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*Numbness | *Numbness | ||
**Check supraorbital, infraorbital, and mental nerves | **Check supraorbital, infraorbital, and mental nerves | ||
*Assess Le Fort by rocking hard palate | *Assess Le Fort by rocking hard palate with one hand while stabilizing forehead with other | ||
===Eye=== | ===Eye=== | ||
*Exam | *Exam | ||
**Bird's eye view for exophthalmos | **Bird's eye view for exophthalmos with retrobulbar hematoma | ||
**Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture) | **Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture) | ||
*Acuity | *Acuity | ||
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**Monocular diplopia suggets lens dislocation | **Monocular diplopia suggets lens dislocation | ||
*Extraocular motion | *Extraocular motion | ||
**Limitation on upward gaze occurs | **Limitation on upward gaze occurs with fracture of inf and medial orbital wall | ||
*Pupil | *Pupil | ||
**Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test) | **Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test) | ||
*Pressure (only if r/o globe rupture) | *Pressure (only if r/o globe rupture) | ||
**Check in patients | **Check in patients with exophthalmos, afferent nerve defect or evidence of retrobulbar hematoma | ||
*Fat through wound = septal perforation | *Fat through wound = septal perforation | ||
*Raccoon eyes | *Raccoon eyes | ||
Revision as of 12:39, 12 July 2016
Background
Prehospital Care
- Assess patients ability to speak and protect the airway before and frequently during transport
- Hematomas can significantly distort pharyngeal and facial anatomy making intubation or cricothyroidotomy difficult
- Increased jaw mobility from a mid face fracture may help with intubation
- Penetrating trauma to the lower third of the face frequently requires intubation or a surgical airway[1]
- Place a protective shield over an eye suspected to have a ruptured globe
- Patients should remain upright or reverse trendelenberg if there is oropharyngeal and nasal bleeding to avoid aspiration especially if placed in cervical protection
- Temporizing hemostasis with oral and nasal packing in an intubated patient may help with persistent bleeding
- Transport all avulsed pieces of the face including ears and nose
Pediatric Considerations
- Cricothyrotomy is contraindicated in patients <8yr old
- Maxillary sinuses do not develop until 6 yr old (reduces midfacial fracture)
- Pediatric orbital floor is more pliable, more likely to lead to entrapment
- Mandible fracture requires prompt referral (1-2d) due to rapid bone remodeling
Clinical Features
Face
- Numbness
- Check supraorbital, infraorbital, and mental nerves
- Assess Le Fort by rocking hard palate with one hand while stabilizing forehead with other
Eye
- Exam
- Bird's eye view for exophthalmos with retrobulbar hematoma
- Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture)
- Acuity
- Diplopia
- Binocular diplopia suggests entrapment of EOM
- Monocular diplopia suggets lens dislocation
- Extraocular motion
- Limitation on upward gaze occurs with fracture 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 patients with exophthalmos, afferent nerve defect or evidence of retrobulbar hematoma
- Fat through wound = septal perforation
- Raccoon eyes
Nose
- Crepitus over any facial sinus suggests sinus fracture
- Septal Hematoma
- Make sure simple nasal fracture 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 Fracture
- Place finger in auditory canal while patient opens and closes jaw to detect condyle fracture
- Tongue blade test
- 95% Sn for no fracture if can bite down hard enough to break it when twisted by examiner
- Jaw deviation due to mandible dislocation or condyle fracture
- Chin will point away from dislocation, towards a fracture
- Malocclusion occurs in mandible, zygomatic, and Le Fort fracture
- Lacerations and mucosal ecchymosis suggests mandible fracture
Differential Diagnosis
Maxillofacial Trauma
- Ears
- Nose
- Oral
- Other face
- Zygomatic arch fracture
- Zygomaticomaxillary (tripod) fracture
- Related
Diagnosis
- Suspect midface fracture > facial CT
- Suspect orbital floor fracture > orbital CT
- Suspect mandibular fracture
- Mandibular series
- Body fracture > oblique view
- Angle/symphysis fracture > PA view
- Condyle fracture > AP axial (Towne's) view
- Mandibular series
- Plain Films
- Water's view
- Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
- Bucket handle view
- zygomatic arches
- Water's view
Disposition
- Bedside consult is necessary for:
- Decreased vision
- Tripod Fracture
- Le Fort Fracture
- Open Mandibular Fracture
- Frontal Sinus Fractures with intracranial involvement
See Also
References
- ↑ Hollier L. et al. Facial gunshot wounds: A 4-year experience. Journal of Oral and Maxillofacial Surgery. 2011: 59:277-282