Pathognomonic clinical signs of traumatic tissue maxillofacial area in children. Modern diagnostic methods. The principles of therapeutic tactics in injuries.

Pathognomonic clinical signs of traumatic tissue maxillofacial area in children. Modern diagnostic methods. The principles of therapeutic tactics in injuries of the soft tissues of the face, teeth, bones. Diagnosis, differential diagnosis and treatment of TMJ ankilosis. Modern principles of treatment and rehabilitation of children with congenital maxillo facial area.

Management of traumatized patient
Maxillofacial trauma Management of traumatized patient

Causes: △ Road traffic accident (RTA) 35-60%
Rowe and Killey 1968; Vincent-Towned and Shepherd 1994 △ Fight and assault (interpersonal violence) Most in economically prosperous countries Beek and Merkx 1999 △ Sport and athletic injuries △ Industrial accidents △ Domestic injuries and falls

Incidence Literatures reported different incidence in different parts of the WORLD and at different TIMES √ 11% in RTA (Oikarinen and Lindqvist 1975) Mandible (61%) Maxilla (46%) Zygoma (27%) Nasal (19.5%)

Factors affecting the high/low incidence of maxillofacial trauma
Geography Fight, gunshot and RTA in developed and developing countries respectively (Papavassiliou 1990, Champion et al 1997) Social factors Violence in urban states (Telfer et al 1991; Hussain et al 1994; Simpson & McLean 1995) Alcohol and drugs Yong men involved in RTA wile they are under alcohol or drug effects (Shepherd 1994) Road traffic legislation Seat belts have resulted in dramatic decrease in injury (Thomas 1990, as reflected in reduction in facial injury (Sabey et al 1977) Season Seasonal variation in temperature zones (summer and snow and ice in midwinter) of RTA, violence and sporting injuries (Hill et al 1998)

Assessment of traumatized patient
This should not concentrate on the most obvious injury but involve a rapid survey of the vital function to allow management priorities 5% of all deaths world wide are caused by trauma This might be much higher in this country

Peaks of mortality First peak
Occurs within seconds of injury as a result of irreversible brain or major vascular damage Second peak Occurs between a few minutes after injury and about one hour later (golden hour) Third peak Occurs some days or weeks after injury as a result of multi-organ failure

Organization of trauma services
triage decisions are crucial in determining individual patients survival Pre-hospital care (field triage) Care delivered by fully trained paramedic in maintaining airway, controlling cervical spine, securing intravenous and initiating fluid resuscitation Hospital care (inter-hospital triage) Senior medical staff organized team to ensure that medical resources are deployed to maximum overall benefit Mass casualty triage

Primary survey Ⓐ Airway maintenance with cervical spine control
Ⓑ Breathing and ventilation Ⓒ Circulation with hemorrhage control Ⓓ Disability assessment of neurological status Ⓔ Exposure and complete examination of the patient

Airway Satisfactory airway signifies the implication of breathing and ventilation and cerebral function Management of maxillofacial trauma is an integral part in securing an unobstructed airway Immobilization in a natural position by a semi-rigid collar until damaged spine is excluded

Sequel of facial injury
Obstruction of airway asphyxia Cerebral hypoxia Brain damage/ death Is the patient fully conscious? And able to maintain adequate airway? Semiconscious or unconscious patient rapidly suffocate because of inability to cough and adopt a posture that held tongue forward

Immediate treatment of airway obstruction in facial injured patient
△Clearing of blood clot and mucous of the mouth and nares and head position that lead to escape of secretions (sit-up or side position) △ Removal of foreign bodies as a broken denture or avulsed teeth which can be inhaled and ensuring the patency of the mouth and oropharynex △ Controlling the tongue position in case of symphesial bilateral fracture of mandible and when voluntary control of intrinsic musculature is lost △ Maintaining airway using artificial airway in unconscious patient with maxillary fracture or by nasophryngeal tube with periodic aspiration △ Lubrication of patient’s lips and continuous supervision

Additional methods in preservation of the airway in patient with severe facial injuries
Endotracheal intubation Needed with multiple injuries, extensive soft tissue destruction and for serious injury that require artificial ventilation Tracheostomy Surgical establishment of an opening into the trachea Indications: 1. when prolonged artificial ventilation is necessary 2. to facilitate anesthesia for surgical repair in certain cases 3. to ensure a safe postoperative recovery after extensive surgery 4. following obstruction of the airway from laryngeal edema 5. in case of serious hemorrhage in the airway Circothyroidectomy An old technique associated with the risk of subglottic stenosis development particularly in children. The use of percutaneous dilational treachestomy (PDT) in MFS is advocated by Ward Booth et al (1989) but it can be replaced with PDT. Control of hemorrhage and Soft tissue laceration Repair, ligation, reduction of fracture and Postnasal pack

Cervical spine injury Can be deadly if it involved the odontoid process of the axis bone of the axis vertebra If the injury above the clavicle bone, clavicle collar should minimize the risk of any deterioration

Breathing and ventilation
Chest injuries: Pneumothorax, haemopneumothorax, flail segments, reputure daiphram, cardiac tamponade signs Clinical Deviated trachea Absence of breath sounds Dullness to percussion Paradoxical movements Hyper-response with a large pneumothorax Muffled heart sounds Radiographical Loss of lung marking Deviation of trachea Raised hemi-diaphragm Fluid levels Fracture of ribs

Emergency treatment in case of chest injury
Occluding of open chest wounds Endotreacheal intubation for unstable flail chest Intermittent positive pressure ventilation Needle decompression of the pericardium Decompression of gastric dilation and aspiration of stomach content

Circulation Circulatory collapse leads to low blood pressure, increasing pulse rate and diminished capillary filling at the periphery Patient resuscitation Restoration of cardio-respiratory function Shock management Replacement of lost fluid

Fluid for resuscitation: ☞Adequate venous access at two points
☞ Hypotension assumed to be due to hypovolaemia ☞ Resuscitation fluid can be crystalloid, colloid or blood; ringer lactate ☞ Surgical shock requires blood transfusion, preferably with cross matching or group O+ ☞ Urine output must be monitored as an indicator of cardiac out put

Reduction and fixation will often arrest bleeding of long duration
Pulse and blood pressure should be monitored and appropriate replacement therapy is to be started

Neurological deficient
Rapid assessment of neurological disability is made by noting the patient response on four points scale: A Response appropriately, is Aware V Response to verbal stimuli P Response to painful stimuli U Does not responds, Unconscious

Glasgow coma scale (GCS) (Teasdale and Jennett, 1974)
Eye opening Motor response Verbal response Spontaneous 4 Move to command 6 Converse 5 To speech 3 Localizes to pain Confused To pain 2 Withdraw from pain Gibberish none 1 flexes grunts Extends Score 8 or less indicates poor prognosis, moderate head injury between 9-12 and mild refereed to 13-15

Exposure All trauma patient must be fully exposed in a warm environment to disclose any other hidden injuries When the airway is adequately secured the second survey of the whole body is to be carried out for: Accurate diagnosis Maintenance of a stable state Determination of priorities in treatment Appropriate specialist referral

Secondary survey Although maxillofacial injuries is part of the secondary survey, OMFS might be involved at early stage if the airway is compromised by direct facial trauma Head injury Abdominal injury Injury to extremities

Head injury Many of facial injury patients sustain head injury in particular the mid face injuries
Open Closed it is ranged from Mild concussion to brain death

Signs and symptoms of head injury
Loss of conscious OR History of loss of conscious History of vomiting Change in pulse rate, blood pressure and pupil reaction to light in association with increased intracranial pressure Assessment of head injury (behavioral responses “motor and verbal responses” and eye opening) Skull fracture Skull base fracture (battle’s sign) Temporal/ frontal bone fracture Naso-orbital ethmoidal fracture

slow reaction and fixation of dilated pupil denotes a rise in intra-cranial pressure
Rise in intercranial pressure as a result of acute subdural or extradural hemorrhage deteriorate the patient’s neurological status Apparently stable patient with suspicion of head injury must be monitored at intervals up to one hour for 24 hour after the trauma

Acute bleeding may lead to hemorrhagic shock and circulatory collapse
Hemorrhage Acute bleeding may lead to hemorrhagic shock and circulatory collapse Abdominal and pelvis injury; liver and internal organs injury (peritonism) Fracture of the extremities (femur)

Abdomen and pelvis In addition to direct injuries, loss of circulating blood into peritoneal cavity or retroperitonial space is life threatening, indicated by physical signs and palpation, percussion and auscultation Management: Diagnostic peritoneal lavage (DPL) to detect blood, bowel content, urine Emergency laprotomy

Extremity trauma Fracture of extremities in particular the femur can be a significant cause of occult blood loss. Straightening and reduction of gross deformity is part of circulation control Cardinal features of extremities injury Impaired distal perfusion (risk of ischemia) Compartment syndrome (limb loss) Traumatic amputation

Patient hospitalization and determination of priorities Facial bone fracture is hardly ever an urgent procedure, simple and minor injury of ambulant patient may occasionally mask a serious injury that eventually ended the patient’s life △ emergency cases require instant admission △ conditions that may progress to emergency △ cases with no urgency

Preliminary treatment in complex facial injury
Soft tissue laceration (8 hours of injury with no delay beyond 24 hours) Support of the bone fragments Injury to the eye As a result of trauma, 1.6 million are blind, 2.3 million are suffering serious bilateral visual impairment and 19 million with unilateral loss of sight (Macewen 1999) Ocular damage Reduction in visual acuity Eyelid injury

Prevention of infection Fractures of jaw involving teeth bearing areas are compound in nature and midface fracture may go high, leading to CSF leaks (rhinorrhoea, otorrhoea) and risk of meningitis, and in case of perforation of cartilaginous auditory canal Diagnosis: Laboratory investigation, CT and MRI scan Management: Dressing of external wounds Closure of open wounds Reposition and immobilization of the fractures Repair of the dura matter Antibacterial prophylaxis (as part of the general management (Eljamal, 1993)

Control of pain Displaced fracture may cause severe pain but strong analgesic ( Morphine and its derivatives) must be avoided as they depress cough reflex, constrict pupils as they may mask the signs of increasing intracranial pressure Management: ☞ Non-steroidal anti-inflammatory drugs can be prescribed (Diclofenac acid) ☞ Reduction of fracture ☞ sedation

In patient care Necessary medications
Diet (fluid, semi-fluid and solid food) intake and output (fluid balance chart) Hygiene and physiotherapy Proper timing for surgical intervention

Pathophysiology Maxillofacial fractures result from either blunt or penetrating trauma. Penetrating injuries are more common in city hospitals. Midfacial and zygomatic injuries. Blunt injuries are more frequently seen in community hospitals. Nose and mandibular injuries. Maxillofacial fractures result from either blunt or penetrating trauma. Penetrating injuries are more common in city hospitals. Midfacial and zygomatic injuries. Blunt injuries are more frequently seen in community hospitals. Nose and mandibular injuries.

Pathophysiology High Impact: Low Impact: Supraorbital rim – 200 G
Symphysis of the Mandible –100 G Frontal – 100 G Angle of the mandible – 70 G Low Impact: Zygoma – 50 G Nasal bone – 30 G The amount of force to fracture different facial bones have been studied and have been divided into High impact (greater then 50 times gravity) and Low Impact (less then 50 times gravity). High Impact: Supraorbital rim – 200 G Symphysis of the Mandible –100 G Frontal – 100 G Angle of the mandible – 70 G Low Impact: Zygoma – 50 G Nasal bone – 30 G

Etiology @60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise. 20-50% concurrent brain injury. 1-4% cervical spine injuries. Blindness occurs in 0.5-3% @60% of patients with severe facial trauma have multisystem trauma and the potential for airway compromise. As many as 20-50% of the patients with facial trauma sustain concurrent brain injury, especially those with upper face and midface fractures. 1-4% of these patients have cervical spine injuries. Remember to always r/o cervical spine injuries clinically and radiographically in such patients. Blindness can occur in .5-3% of these trauma pts and are mostly seen in patients with Lefort 3 (2.2%) and Lefort 2 (.64%).

Etiology 25% of women with facial trauma are victims of domestic violence. Increases to 30% if an orbital wall fx is present. 25% of patients with severe facial trauma will develop Post Traumatic Stress Disorder As many as one forth of the women with facial trauma are victims of domestic violence. If a women has an orbital fracture, the likelihood of sexual assault or domestic violence increases to more then 30%. In addition to physical consequences of facial trauma, there are psychological costs as well. More then a one quarter of patients with severe facial trauma will develop Post Traumatic Stress Disorder.

Anatomy

Emergency Management Airway Control
Control airway: Chin lift. Jaw thrust. Oropharyngeal suctioning. Manually move the tongue forward. Maintain cervical immobilization Emergency management consists of Controlling the airway: Chin lift. Jaw thrust. Oropharyngeal suctioning. Manually move the tongue forward. Maintain cervical immobilization

Emergency Management Intubation Considerations
Avoid nasotracheal intubation: Nasocranial intubation Nasal hemorrhage Avoid Rapid Sequence Intubation: Failure to intubate or ventilate. Consider an awake intubation. Sedate with benzodiazepines. Since the cribiform plate may be disrupted, avoid nasotracheal intubation. Nasotracheal intubation can result in nasocranial intubation or dramatic nasal hemorrhage. RSI carries a particular risk in facial trauma. These include failure to intubate and subsequent failure to ventilate with a bag valve mask 2nd to facial distortion and should also be avoided. Consider awake intubation and use Benzodiazepines or another induction agent that minimizes resp. depression. If paralytics are used, be prepared for immediate backup cricothyroidotomy.

Emergency Management Intubation Considerations
Consider fiberoptic intubation if available. Alternatives include percutaneous transtracheal ventilation and retrograde intubation. Be prepared for cricothyroidotomy. If available, fiberoptic intubation may be helpful. Other alternatives include percutaneous transtracheal ventilation and retrograde intubation. Always be prepared to perform cricothyroidotomy.

Emergency Management Hemorrhage Control
Maxillofacial bleeding: Direct pressure. Avoid blind clamping in wounds. Nasal bleeding: Anterior and posterior packing. Pharyngeal bleeding: Packing of the pharynx around ET tube. Bleeding from facial injuries typically is profuse but rarely causes hypovolemia or shock. In hypotensive patients, look for other sources of blood loss such as intrathoracic, intraabdominal, and retroperitoneal hemorrhage. Try to control bleeding with direct pressure. Blind clamping should be avoided because injury to important nonvascular structures such as the facial nerve and parotid duct can result. Anterior and posterior packing may be needed in patients with nasal bleeding that does not resolve with direct pressure alone. Pharyngeal bleeding may require packing around the ET tube. Once the airway is secured and gross hemorrhage is controlled, only then search for life threatening injuries to the chest, abd and pelvis.

History Obtain a history from the patient, witnesses and or EMS.
AMPLE history Specific Questions: Was there LOC? If so, how long? How is your vision? Hearing problems? After your ABC’s and all life threatening injuries have been addressed, Obtain a history from the pt, witnesses and or EMS. A-allergies, M-medications, P-pmedhx, L-last meal, E-events leading to the injury. Specific questions: Was there LOC? If so,how long? How is your vision? Monocular double vision-lens dislocation, corneal/retinal injury. Binocular double vision- dysfunction of the EOM or nerves.

History Specific Questions: Is there pain with eye movement?
Are there areas of numbness or tingling on your face? Is the patient able to bite down without any pain? Is there pain with moving the jaw? Ask specific questions.: Is there pain with eye movement?-injury to the globe, orbit Are there areas of numbness or tingling on your face?-nerve entrap. Is the patient able to bite down without any pain? Is there pain with moving the jaw?-fx, impingement temporalis m.

Physical Examination Inspection of the face for asymmetry.
Inspect open wounds for foreign bodies. Palpate the entire face. Supraorbital and Infraorbital rim Zygomatic-frontal suture Zygomatic arches Inspection of the face for asymmetry.Best done at the head of the bed. Ask the patient to smile, frown, whistle, raise their eyebrows, close their eyes. Inspect open wounds for foreign bodies. Palpate the entire face. Supraorbital and Infraorbital rim Zygomatic-frontal suture Zygomatic arches Note ecchymosis (Battle’s sign, Raccoon eyes)

Physical Examination Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge. Inspect nasal septum for septal hematoma, CSF or blood. Palpate nose for crepitus, deformity and subcutaneous air. Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone. Inspect the nose for asymmetry, telecanthus, widening of the nasal bridge. Measure the distance between the medial canthi. In normal patients the distance is 35-40mm. If its greater then 40 mm you should suspect nasoethmoid-orbital trauma. Inspect nasal septum for septal hematoma, CSF or blood. (place a drop of blood on a paper towel and look for a halo sign, nonspecific). Palpate nose for crepitus, deformity and subcutaneous air. Palpate the zygoma along its arch and its articulations with the maxilla, frontal and temporal bone.

Physical Examination Check facial stability.
Inspect the teeth for malocclusions, bleeding and step-off. Intraoral examination: Manipulation of each tooth. Check for lacerations. Stress the mandible. Tongue blade test. Palpate the mandible for tenderness, swelling and step-off. Open pts mouth and grasp the maxilla arch, place the other hand on the forehead. Push back and forth, up and down and check for movement. Inspect the teeth for malocclusions, bleeding and step-off. If teeth are missing, account for to be sure they have not been aspirated. Intraoral exam: Manipulate each tooth, check for lacerations, stress the mandible, tongue blade test. (Bite down on the tongue blade, Twist the blade to try to break it. Pts with broken jaw will reflexively open their mouth.) 95% sensitive and 65% specific. Palpate the mandible for tenderness, swelling and step-off.

Physical Examination Check visual acuity.
Check pupils for roundness and reactivity. Examine the eyelids for lacerations. Test extra ocular muscles. Palpate around the entire orbits.. Check visual acuity. Snell chart, finger counting or presence or absence of light perception. Check pupils for roundness and reactivity. Tear drop pupil – ruptured or penetrated globe injury. Examine for exopthalmus or enopthalmus Examine the lids for lacerations. Check for injuries to the medial 3rd of the eyelids for damage to the lacrimal apparatus. Check for disruption of the levator palpebral muscles. Test extra ocular muscles.Testing for restriction. Restriction of upward gaze can be seen with zygomatic or infra orbital wall fx’s. Palpate around the entire orbits. Tenderness, subcutaneous air and deformity. Palpate the medial orbit area to r/o naso ethmoidal orbital fx. (place a Q tip inside the nose to the medial canthus, place your finger outside the medial canthus. If the bone moves NEO fx.)

Physical Examination Examine the cornea for abrasions and lacerations.
Examine the anterior chamber for blood or hyphema. Perform fundoscopic exam and examine the posterior chamber and the retina. Examine the cornea for abrasions and lacerations. Fluorescein if needed. Examine the anterior chamber for blood or hyphema. When the patient is stable try to do a slit lamp examination. Perform fundoscopic exam and examine the posterior chamber and the retina. Looking for retinal detachment.

Physical Examination Examine and palpate the exterior ears.
Examine the ear canals. Check nuero distributions of the supraorbital, infraorbital, inferior alveolar and mental nerves. Examine and palpate the exterior ears. Look for ecchymosis, hematomas,battle sign. Examine the ear canal. Look for lacerations, TM ruptures, Place your finger into the ear canal and have the pt open their mouth to check for condylar fx or dislocation. Check nuero distributions of the supraorbital, infraorbital, inferior alveolar and mental nerves. Supraorbital n.- forehead and vertex of scalp. Infraorbital n.- midface,maxillary incisors and premolar teeth, upper lip, lower eyelid, side of nose. Inferior alveolar n.- mandibular teeth, lower lip and chin. Mental n.- chin and lower lip.

Frontal Sinus/ Bone Fractures Pathophysiology
Results from a direct blow to the frontal bone with blunt object. Associated with: Intracranial injuries Injuries to the orbital roof Dural tears Frontal bone and sinus injuries usually are a result from a direct blow to the frontal bone with a blunt object. Classically a lead pipe or brick. They may also result from motor vehicle trauma in which the patients head strikes the dashboard. This fracture is frequently associated with intracranial injury, secondary to disruption of the posterior table of the sinus. Dural tears are frequent and patients may have associated injuries to the orbital roof.

Frontal Sinus/ Bone Fractures Clinical Findings
Disruption or crepitance orbital rim Subcutaneous emphysema Associated with a laceration Examination usually demonstrates step off, crepitance or subcutaneous emphysema of the supraorbital rim. Often, there is an associated laceration. All open wounds should be inspected for foreign body and bony injury. Remember, patients with frontal sinus fractures require through head, neck, and neurological exam, including ophthalmologic consultation. Picture: Fracture defect seen at the base of a laceration over the frontal sinus.

Frontal Sinus/ Bone Fractures Diagnosis
Radiographs: Facial views should include Waters, Caldwell and lateral projections. Caldwell view best evaluates the anterior wall fractures. Patients with a suggested mechanism or PE should get either skull films, or a caldwell view of the face. (Caldwell view is the best for anterior wall fx’s.). Picture: Caldwell view

Frontal Sinus/ Bone Fractures Diagnosis
CT Head with bone windows: Frontal sinus fractures. Orbital rim and nasoethmoidal fractures. R/O brain injuries or intracranial bleeds. CT scan of the head with bone windows should be done to r/o intracranial pathology, but also to r/o depressed or posterior fx’s. Picture: CT of a patient which demonstrates a fracture of the anterior table of the frontal sinus.

Frontal Sinus/ Bone Fractures Treatment
Patients with depressed skull fractures or with posterior wall involvement. ENT or nuerosurgery consultation. Admission. IV antibiotics. Tetanus. Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery. Patients with depressed skull fractures or with posterior wall involvement require: ENT or nuerosurgery consultation. Admission. IV antibiotics. Tetanus. Patients with isolated anterior wall fractures, nondisplaced fractures can be treated outpatient after consultation with neurosurgery.

Frontal Sinus/ Bone Fractures Complications
Associated with intracranial injuries: Orbital roof fractures. Dural tears. Mucopyocoele. Epidural empyema. CSF leaks. Meningitis. Associated with with intracranial injuries: Orbital roof fractures. Dural tears. Mucopyocoele. Epidural empyema. CSF leaks. Meningitis.

Naso-Ethmoidal-Orbital Fracture
Fractures that extend into the nose through the ethmoid bones. Associated with lacrimal disruption and dural tears. Suspect if there is trauma to the nose or medial orbit. Patients complain of pain on eye movement. NEO fracture is defined as a fracture that extends into the nose through the ethmoid bones. These fractures are associated with lacrimal disruption and dural tears. Suspect this type of a fracture if there is trauma to the nose or medial orbit. Patients typically complain of pain on eye movement.

Clinical findings: Flattened nasal bridge or a saddle-shaped deformity of the nose. Widening of the nasal bridge (telecanthus) CSF rhinorrhea or epistaxis. Tenderness, crepitus, and mobility of the nasal complex. Intranasal palpation reveals movement of the medial canthus. Clinical findings: Flattened nasal bridge or a saddle-shaped deformity of the nose. Widening of the nasal bridge - telecanthus CSF rhinorrhea or epistaxis. Tenderness, crepitus, and mobility of the nasal complex. Intranasal palpation reveals movement of the medial canthus.

Imaging studies: Plain radiographs are insensitive. CT of the face with coronal cuts through the medial orbits. Treatment: Maxillofacial consultation. ? Antibiotic Plain radiographs are insensitive. If the examination is suggestive, order a CT of the face to include coronal sections and thin axial slices through the medial orbit wall. If an NEO fracture is present, consult a maxillofacial surgeon. As with many facial fractures, AB’s are frequently prescribed for CSF leaks, but their efficacy is question.

Nasal Fractures Most common of all facial fractures.
Injuries may occur to other surrounding bony structures. 3 types: Depressed Laterally displaced Nondisplaced Most common of all facial fractures. Injuries may occur to other surrounding bony structures. Including fx’s to the orbit, frontal sinus, or cribiform plate. Suspect these injuries if the patient had LOC, Hx of a mechanism with significant force or findings of facial bone injuries. 3 types of nasal fx’s: Depressed Laterally displaced Nondisplaced

Nasal Fractures Ask the patient:
“Have you ever broken your nose before?” “How does your nose look to you?” “Are you having trouble breathing?” Ask the patient: “Have you ever broken your nose before?” “How does your nose look to you?” “Are you having trouble breathing?” You want to ask these questions because nasal trauma may be do to old or new trauma.

Nasal Fractures Clinical findings: Nasal deformity
Edema and tenderness Epistaxis Crepitus and mobility On physical exam, observe deformity, palpate for crepitus and mobility. It is important to do an intra nasal exam to inspect for bleeding and for a septal hematoma. If clear rhinorrhea is present, suspect other injuries, such as fx’s to the ethmoid bone. Picture: Deformity is evident on examination. Note peri-ocular ecchymosis indicating the possibility of other injuries.

Nasal Fractures Diagnosis: History and physical exam.
Lateral or Waters view to confirm your diagnosis. Nasal bone fx’s can be dx clinically by hx and physical examination. Plain nasal films consisting of a lateral view or a Waters view can confirm your dx but are of little practical use. Picture: Radiograph of a displaced fracture of the nasal spine, for which no treatment other then ice and analgesics is needed.

Nasal Fractures Treatment: Control epistaxis. Drain septal hematomas.
Refer patients to ENT as outpatient. Treatment: Control epistaxis: Direct pressure Topical vasoconstrictor such as phenylephrine 1% or cocaine Cauterize with silver nitrate. Nasal packing ant/post packing. Draining septal hematoma’s. anesthetize the area. Using a # 11 blade incise the inferior portion of the hematoma and allow it to drain. Then pack the nose with vaseline gauze to prevent reacumulation of blood. If there is no epistaxis or deformity, treat the patient with ice and analgesics. If obvious deformity is present, including new septal deviation or deformity, treat with ice and analgesics and refer to ENT in 2-5 days for reduction. Picture: This is a picture of a septal hematoma, Notice a blueish, grapelike mass on the nasal septum. If untreated, this can result in septal necrosis and a saddle nose deformity.

Orbital Blowout Fractures
Blow out fractures are the most common. Occur when the the globe sustains a direct blunt force 2 mechanisms of injury: Blunt trauma to the globe Direct blow to the infraorbital rim Blowout fx’s are the most common of the orbital fx’s. They occur when the globe sustains direct blunt force. The first is a true blowout fx, where all the energy is transmitted to the globe. Since the spherical globe is stronger than the thin orbital floor, the force is then transmitted to the thin orbital floor or medially through the ethmoid bones with the resultant fx. The object causing the injury must be smaller then 5-6cm, otherwise the globe is protected by the surrounding orbit. Fists or small balls are the typical causative agents. The second mechanism occurs when the energy from the blow is transmitted to the to the infraorbital rim causing a buckling of the floor. Entrapment and globe injury is less likely with this injury.

Orbital Blowout Fractures Clinical Findings
Periorbital tenderness, swelling, ecchymosis. Enopthalmus or sunken eyes. Impaired ocular motility. Infraorbital anesthesia. Step off deformity Patients usually present with: 1. Periorbital tenderness, swelling, ecchymosis. 2. Enopthalmus or sunken eyes. 3. Impaired ocular motility. Usually caused by entrapment of the inferior rectus muscle. 4. Infraorbital anesthesia. This develops when the infraorbital nerve is contused by the initial trauma or when the compressed by bony fragments. Anesthesia of the maxillary teeth and upper lip is more reliable then numbness over the cheek. 5. Step off deformity can be appreciated over the infraorbital rim. Subcutaneous emphysema is pathognomonic for a fracture into a sinus or nasal antrum. Picture: The inferior rectus muscle is entrapped within the blow out fx. When the patient tries to look upward, the affected eye has limited upward gaze. The patient experiences diplopia with this maneuver.

Orbital Blowout Fractures Imaging studies
Radiographs: Hanging tear drop sign Open bomb bay door Air fluid levels Orbital emphysema Facial films should consist of Waters, Caldwell and lateral projections. Waters view is the best for displaying the inferior orbital rims. When reading the films look for the following: Hanging tear drop sign-herniation of the periorbital fat into the maxillary sinus. Open bomb bay door or trap door sign- Bony fragments protrude into the maxillary sinus. Air fluid levels- and maxillary clouding secondary to bleeding. Orbital emphysema X ray: Demonstrates a fx of the floor of the R orbit, with a tear drop sign due to the extruded orbital contents. There is a associated air fluid level in the maxillary sinus due to blood. Atlas pg 15.

Orbital Blowout Fractures Imaging studies
CT of orbits Details the orbital fracture Excludes retrobulbar hemorrhage. CT Head R/o intracranial injuries CT of the orbits with coronal cuts is considered the DOC, Higher sensitivity then radiographs and helps with the planning operative repair. Picture: Ct of a patient demonstrating the entrapped muscle extruding into the maxillary sinus.

Orbital Blowout Fractures Treatment
Blow out fractures without eye injury do not require admission Maxillofacial and ophthalmology consultation Tetanus Decongestants for 3 days Prophylactic antibiotics Avoid valsalva or nose blowing Patients with serious eye injuries should be admitted to ophthalmology service for further care. Blow out fractures without eye injury do not require admission Maxillofacial and ophthalmology consultation Tetanus Decongestants for 3 days Prophylactic antibiotics Avoid valsalva or nose blowing Patients with serious eye injuries should be admitted to ophthalmology service for further care.

Zygoma Fractures The zygoma has 2 major components:
Zygomatic arch Zygomatic body Blunt trauma most common cause. Two types of fractures can occur: Arch fracture (most common) Tripod fracture (most serious) The zygoma has 2 major components, the zygomatic arch and the body. The arch forms the the inferior and lateral orbit, and the body forms the malar eminence of the face. Fractures to the zygoma are usually the result of blunt trauma. Direct blow to the arch can result in isolated arch fractures. These are the most common. While tripod fractures are more serious and are caused by more extensive trauma.

Zygoma Arch Fractures Can fracture 2 to 3 places along the arch
Lateral to each end of the arch Fracture in the middle of the arch Patients usually present with pain on opening their mouth. Zygoma arch fractures can fracture in 2-3 places along the arch. 1. Lateral to each end of the arch. 2. Fracture in the middle of the arch causing a V fracture which could impinge on the temporalis muscle. Patients usually present with pain on opening their mouth.

Zygoma Arch Fractures Clinical Findings
Palpable bony defect over the arch Depressed cheek with tenderness Pain in cheek and jaw movement Limited mandibular movement Clinical findings: Palpable bony defect over the arch Depressed cheek with tenderness on palpation. Pain in cheek and jaw movement and limited mandibular movement which is due to impingement of the coronoid process of the mandible on the arch during mouth opening or impingement of the temporalis muscle. Picture: patient with blunt trauma to the zygoma. Flattening of the right malar eminence is evident.

Zygoma Arch Fractures Imaging Studies & Treatment
Radiographic imaging: Submental view (bucket handle view) Treatment: Consult maxillofacial surgeon Ice and analgesia Possible open elevation X-ray: bucket handle view of the zygomatic arch demonstrating a depressed fracture. Treatment: Consult maxillofacial surgeon Ice and analgesia Possible open elevation if cosmetic correction is desired or if there is entrapment of the mandible persists.

Zygoma Tripod Fractures
Tripod fractures consist of fractures through: Zygomatic arch Zygomaticofrontal suture Inferior orbital rim and floor Tripod fractures consist of fractures through: Zygomatic arch Zygomaticofrontal suture Inferior orbital rim and floor Picture: Diagram of a tripod fracture. Note the disruption of both the lateral orbital rim and the orbital floor, as well as the zygomatic arch.

Zygoma Tripod Fractures Clinical Features
Periorbital edema and ecchymosis Hypesthesia of the infraorbital nerve Palpation may reveal step off Concomitant globe injuries are common Clinical features: Periorbital edema and ecchymosis Hypesthesia of the infraorbital nerve Palpation may reveal step off Concomitant globe injuries are common

Zygoma Tripod Fractures Imaging Studies
Radiographic imaging: Waters, Submental and Caldwell views Coronal CT of the facial bones: 3-D reconstruction Plain films including the waters, submental and caldwell views. Can demonstrate the fracture and evaluate the zygomaticomaxillary complex, but a Coronal CT of the facial bones will best show involvement and the degree of displacement. Picture: CT 3-D. The fracture lines involved in a tripod fracture are demonstrated in this 3-D reconstruction.

Zygoma Tripod Fractures Treatment
Nondisplaced fractures without eye involvement Ice and analgesics Delayed operative consideration 5-7 days Decongestants Broad spectrum antibiotics Tetanus Displaced tripod fractures usually require admission for open reduction and internal fixation. Maxillofacial consultation Nondisplaced fractures without eye involvement Ice and analgesics Delayed operative consideration 5-7 days Decongestants Broad spectrum antibiotics since the fracture crosses into the maxillary sinus. Tetanus Displaced tripod fractures usually require admission for open reduction and internal fixation

Maxillary Fractures High energy injuries.
Impact 100 times the force of gravity is required . Patients often have significant multisystem trauma. Classified as LeFort fractures. Fractures of the maxilla are high energy injuries. An impact 100 times the force of gravity is required to break the midface. These patients often have significant multisystem trauma. Many require resuscitation and admission. The fractures of the maxilla are classified as LeFort Fractures.

Maxillary Fractures LeFort I
Definition: Horizontal fracture of the maxilla at the level of the nasal fossa. Allows motion of the maxilla while the nasal bridge remains stable. LeFort I: Horizontal fracture of the maxilla at the level of the nasal fossa. Allows motion of the maxilla while the nasal bridge remains stable. The fracture is below the infraorbital nerve, so there is no hypesthesia.

Clinical findings: Facial edema Malocclusion of the teeth Motion of the maxilla while the nasal bridge remains stable LeFort I: Physical exam: Facial edema Malocclusion of the teeth Motion of the maxilla while the nasal bridge remains stable

Radiographic findings: Fracture line which involves Nasal aperture Inferior maxilla Lateral wall of maxilla CT of the face and head coronal cuts 3-D reconstruction Radiographic findings: Fracture line which involves Nasal aperture Inferior maxilla Lateral wall of maxilla CT of the face with coronal cuts is superior to plain films. Head CT should also be done to r/o intracranial injury.

Maxillary Fractures LeFort II
Definition: Pyramidal fracture Maxilla Nasal bones Medial aspect of the orbits LeFort II: Pyramidal fracture which includes a fracture through: Maxilla Nasal bones Medial aspect of the orbits

Clinical findings: Marked facial edema Nasal flattening Traumatic telecanthus Epistaxis or CSF rhinorrhea Movement of the upper jaw and the nose. Clinical findings: Marked facial edema Nasal flattening Traumatic telecanthus Epistaxis or CSF rhinorrhea Movement of the upper jaw and the nose. Picture: This patient sustained a Lefort II/III fracture.

Radiographic imaging: Fracture involves: Nasal bones Medial orbit Maxillary sinus Frontal process of the maxilla CT of the face and head Plain facial films will reveal the presence of facial fractures, but are less helpful in determining the type or extent . Head and facial CT, including three dimensional re-creations, offer much more useful information.

Maxillary Fractures LeFort III
Definition: Fractures through: Maxilla Zygoma Nasal bones Ethmoid bones Base of the skull Lefort III fractures also known as craniofacial dissociation(separates the face from the cranium) involves fractures through the maxilla, zygoma, nasal bones, ethmoid bones and the bones of the base of the skull.

Clinical findings: Dish faced deformity Epistaxis and CSF rhinorrhea Motion of the maxilla, nasal bones and zygoma Severe airway obstruction Clinical Findings: Patients with LeFort III fractures on physical exam have what’s known as the dish faced deformity which is facial flattening and elongation with the eyes markedly swollen shut. Since the maxilla is pushed inward, the patients mandible appears forward. Epistaxis and CSF rhinorrhea are usually present. Movement of the entire face is noted with distraction. These patients are also at high risk for airway obstruction.

Radiographic imaging: Fractures through: Zygomaticfrontal suture Zygoma Medial orbital wall Nasal bone CT Face and the Head Radiographic imaging: Fractures through: Zygomaticfrontal suture Zygoma Medial orbital wall Nasal bone extending posteriorly through the orbit into the spheno-palatine fossa. Again, head and facial CT will offer more information.

Maxillary Fractures Treatment
Secure and airway Control Bleeding Head elevation degrees Consult with maxillofacial surgeon Consider antibiotics Admission Emergency care for all these fractures involves airway maintenance, with Intubation or cricothyrotomy if necessary. Airway compromise is possible with any of these fractures but probably more common with LeFort II and III fractures. CSF rhinorrhea is uncommon in LeFort I fracture but is often seen in LeFort II and III fractures. If CSF rhinorrhea is present or intracranial air is seen on X ray or an open skull fracture is present, the patient should be admitted and place in a head elevated position (40-60 degrees) if possible. Prophylactic antibiotics are often given in these patients (Rocephin) though it has not been shown to prevent meningitis or brain abscess. Patients with maxillary fractures also have significant epistaxis which requires nasal packing. Operative intervention may be needed if bleeding doe not resolve with packing alone. Look for associated injuries, especially intracranial, spinal, thoracic and abdominal. Incidence of blindness is high for LeFort II and III fractures so it is important to get opth. consultation. Patients with Complex maxillary fractures require admission for open reduction and internal fixation.

Mandible Fractures Pathophysiology
Mandibular fractures are the third most common facial fracture. Assaults and falls on the chin account for most of the injuries. Multiple fractures are seen in greater then 50%. Associated C-spine injuries – 0.2-6%. Following nasal and zygomatic fractures, mandibular fractures are the third most common type of facial fracture. Assault and fall on the chin account for most of the injuries. Because of its ring shape, fractures are often multiple in up to 50% of the cases. The most common area fractured is the 36%. Patients with a mandibular fracture, have a 0.2-6% increased risk of associated C-spine injury.

Mandible Fractures Clinical findings
Mandibular pain. Malocclusion of the teeth Separation of teeth with intraoral bleeding Inability to fully open mouth. Preauricular pain with biting. Positive tongue blade test. These fractures manifest clinically with mandibular pain, tenderness and malocclusion. A step off in the dental line or ecchymosis to the floor of the mouth are often present and is highly suggested of a mandibular fracture. Patients are unable to fully open their mouth. Patients may have preauricular pain with biting when there is a fracture of the condyle. Picture 1: The open fracture line is evident clinically. There is slight mal-alignment of the teeth. Picture 2: Hemorrhage or ecchymosis in the sublingual area is pathognomonic for an mandibular fracture.

Mandible Fractures Radiographs: Panoramic view
Plain view: PA, Lateral and a Townes view The best view for evaluating mandibular trauma is the dental panoramic view. If that is not available, plain films should include AP, bilateral oblique and a townes view to evaluate the condyles. Picture: Dental panoramic view of the mandible. Note fractures in the area of the left angle and right body.

Mandibular Fractures Treatment
Nondisplaced fractures: Analgesics Soft diet oral surgery referral in 1-2 days Displaced fractures, open fractures and fractures with associated dental trauma Urgent oral surgery consultation All fractures should be treated with antibiotics and tetanus prophylaxis. Nondisplaced fractures: Analgesics Soft diet oral surgery referral in 1-2 days Displaced fractures, open fractures and fractures with associated dental trauma Urgent oral surgery consultation, these patients are usually admitted, These patients either need closed reduction with occlusion fixation or open reduction. All patients with mandibular fractures should be treated with antibiotics and tetanus prophylaxis. Antibiotics of choice are PCN, clindamycin or a 1st generation ceph.

Mandibular Dislocation
Causes of mandibular dislocation are: Blunt trauma Excessive mouth opening Risk factors: Weakness of the temporal mandibular ligament Over stretched joint capsule Shallow articular eminence Neurologic diseases Dislocation generally results from a direct blow to chin while the mouth is open, or more commonly in predisposed individuals after a vigorous yawn. Opening the mouth excessively wide while eating or laughing may also result in dislocation. It can also be seen in patients who have had a seizure, and in patients who have had a dystonic reaction from their neuroleptic medication. Weakness of the temporal mandibular ligament, overstretched joint capsule, shallow articular eminence, patients with neurologic diseases which result in increased muscular activity and extrapyramidal effects of neuroleptic medications are predisposing factors.

The mandible can be dislocated: Anterior 70% Posterior Lateral Superior Dislocations are mostly bilateral. The mandible can be dislocated in the anterior, posterior, lateral and superior plane. Anterior dislocation is the most common and occurs when the condyle is forced in front of the articular eminence. Anterior dislocation occurs in up to 70% of the normal individuals but can be spontaneously reduced by the patient. Once the jaw is dislocated, muscular spasm, particularly the temporalis and lateral pterygoid muscles tend to prevent reduction. Dislocations are most frequently bilateral, but they also can be unilateral.

Posterior dislocations: Direct blow to the chin Condylar head is pushed against the mastoid Lateral dislocations: Associated with a jaw fracture Condylar head is forced laterally and superiorly Superior dislocations: Blow to a partially open mouth Condylar head is force upward Posterior dislocations are rare. They occur from a direct blow to the chin that does not break the condylar neck. The condylar head is pushed against the mastoid. As a result the condylar head may prolapse into the external auditory canal. Lateral dislocations are associated with a jaw fracture. With a lateral dislocation the condylar head is forced laterally and superiorly into the temporal space. Superior dislocations occur from a blow to a partially open mouth that forces the condylar head upward. Associated injuries include cerebral contusions, facial nerve palsy and deafness.

Clinical features: Inability to close mouth Pain Facial swelling Physical exam: Palpable depression Jaw will deviate away Jaw displaced anterior Patients present with the inability to close an open mouth. Other associated symptoms include pain, discomfort and facial swelling near the TMJ. Unilateral dislocation results in deviation of the mandible to the unaffected side. Bilateral dislocation causes the mandible to be displace anteriorly. Picture: TMJ Dislocation Note the asymmetric jaw deviation toward the unaffected side. Always consider the possibility of an associated underlying fracture or cervical spine injury.

Diagnosis: History & Physical exam X-rays CT The diagnosis of mandibular dislocation is made by H&P. X-rays should be performed if the Dx is in question or there is Hx of trauma to exclude fracture. Panoramic view usually demonstrates the pathology and excludes other mandibular injuries. If a fracture is still in questioned after X-rays, a CT can be done to provide more information. Picture: Radiograph demonstrates an anterior mandibular dislocation. The location of the condyle is indicated by the open arrow.

Treatment: Muscle relaxant Analgesic Closed reduction in the emergency room Reduction may be attempted in closed anterior dislocations without fracture. A short acting muscle relaxant (Versed) helps to decrease muscle spasm. An analgesic may also be considered. The patient should be seated. Facing the patient the examiner places his or hers thumbs in the patients mouth, over the mandibular molars as far back as possible. The fingers should curve beneath the angle and the body of the mandible. The examiner applies downward and backward pressure with his or hers thumbs until the condyle slides back into the articular eminence. When the dislocation is bilateral, it may be easier to relocate one side at a time. If reduction is successful, the patient should be able to close his or her mouth immediately. Post reduction films are not usually required unless the procedure was difficult or traumatic. Complications from the reduction are unusual and include iatrogenic fracture or avulsion of the articular cartilage.

Treatment: Oral surgeon consultation: Open dislocations Superior, posterior or lateral dislocations Non-reducible dislocations Dislocations associated with fractures Oral surgery should be consulted in patients who are found to have either an open dislocation, superior, posterior or lateral dislocations, non – reducible dislocation or a dislocation associated with a fracture.

Disposition: Avoid excessive mouth opening Soft diet Analgesics Oral surgery follow up Disposition: After successful reduction, patients should be placed on a soft diet and cautioned not to open their mouths more then 2 cm for the following 2 weeks. Analgesics should be prescribed to manage discomfort. Dental follow up should be arranged. Patients with chronic dislocations may require operative intervention.

Pathognomonic clinical signs of traumatic tissue maxillofacial area in children. Modern diagnostic methods. The principles of therapeutic tactics in injuries.

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Pathognomonic clinical signs of traumatic tissue maxillofacial area in children. Modern diagnostic methods. The principles of therapeutic tactics in injuries.

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Presentation on theme: "Pathognomonic clinical signs of traumatic tissue maxillofacial area in children. Modern diagnostic methods. The principles of therapeutic tactics in injuries."— Presentation transcript:

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