Maxillofacial trauma: Difference between revisions
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==Disposition== | ==Disposition== | ||
#Bedside consult is necessary for: | |||
#Decreased vision | ##Decreased vision | ||
#Tripod fractures | ##Tripod fractures | ||
#Lefort fractures | ##Lefort fractures | ||
#Open mandibular fractures | ##Open mandibular fractures | ||
#Frontal sinus fractures with intracranial involvement | ##Frontal sinus fractures with intracranial involvement | ||
==See Also== | ==See Also== |
Revision as of 17:17, 11 June 2012
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 Fracture
- 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
- Mandibular series
- Plain Films
- Water's view
- Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
- Bucket handle view
- zygomatic arches
- Water's view
DDx
- Frontal Sinus Fracture
- 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 Fracture
- 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 Fracture
- Zygomatic Arch Fracture
- Unlikely isolated
- Tripod Fracture
- Fx through:
- 1. inferior orbital rim
- 2. lateral orbital wall
- 3. zygomatic arch
- Must r/o associated ocular injuries
- Usually requires admission and surgical repair
- Fx through:
Fracture Types
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
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:
- Decreased vision
- Tripod fractures
- Lefort fractures
- Open mandibular fractures
- Frontal sinus fractures with intracranial involvement
See Also
Source
Tintinalli's