Maxillofacial trauma: Difference between revisions

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==DDx==
==DDx==
*Frontal Sinus Fracture
*[[Frontal Sinus Fracture]]
**If ant wall fx need CT to evaluate posterior wall (75% have both walls fractured)
**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
**Need neurosurg or ENT for posterior wall fx since many need surgery and IV abx
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**Unlikely isolated
**Unlikely isolated
*[[Tripod Fracture]]
*[[Tripod Fracture]]
*[[Frontal Bone Fracture]]
*[[Orbital Fracture]]
*[[Orbital Fracture]]
*[[Zygomatic Arch Fracture]]
*[[Zygomatic Arch Fracture]]

Revision as of 18:51, 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

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
  • Plain Films
    • Water's view
      • Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
    • Bucket handle view
      • zygomatic arches

DDx

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

  1. 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

Source

Tintinalli's