1. Clerk Mary Angeli A. Conti

2. Treatment Priorities 1. Maintain airway 2. Maintain reasonable cardiac output 3. Evaluation and therapy of any CNS injury 4. Evaluation and therapy of any abdominal and thoracic injury 5. Treatment of soft tissue, facial and extremity trauma 6. Reduction and fixation of facial and extremity fractures

3. Treatment Priorities 1. Maintain airway  Evaluate existence & identification of obstruction  Clear of fractured teeth, bood clots, dentures  Endotracheal intubation  Emergency tracheostomy Last resort Laryngeal injuries

4. Treatment Priorities 2. Maintain reasonable cardiac output  Bleeding controlled by direct pressure  IV catheters 3. Evaluate and therapy of CNS injury  Primary concern: C-spine injury  Avoid any movement of spinal column  Immobilization until spinal injuries are ruled out by: Xray, CT scan, neurologic exam

5. Treatment Priorities 4. Evaluation and therapy of any abdominal and thoracic injury 5. Treatment of soft tissue, facial and extremity trauma 6. Reduction and fixation of facial and extremity fractures

6. History of traumatic event  Time of injury  Detailed description of the instance surrounding the incident Seatbelt Velocities of the vehicle

7. Diagnosis of Maxillofacial Injuries  Inspection  Palpation  Diagnostic Imaging  Plain films  CT

8. Physical Examination  Inspection  Consciousness  Soft tissue covering  Facial mobility  All wounds should be probed  Hemorrhage, Otorrhea, Rhinorrhea, Contour deformity, Ecchymosis, Edema, Continuity defects, Malocclusion

9.  Evaluate for laceration  Obvious depression in skull  Asymmetry  Discharge from nose or ear  Assume CSF leak  Palpation to note bone discontinuity

10.  Palpation  Head & neck, locate displaced fractures  Fracture fragments- “Step” defect  Abnormality frontozygomatic sutures  CSF Fistula  Nose: Septal mobility  Cheeks Pain on compression  zygoma fracture  Mandible  Neck Free air  ruptured tracheobronchial tree, crepitations Tenderness over the larynx  fracture

11. Outline of Discussion  Nasal  Mandibular  Zygoma & Orbital floor  Maxillary  Frontal Sinus  Definition  Signs & Symptoms  Management Types of Fractures

12. Nasal Fracture  Most common bone injury involving the face  Signs of Nasal Fracture 1. Depression or displacement of the nasal bone 2. Edema of the nose 3. Epistaxis 4. Fracture of the septal cartilage with displacement or mobility

13. Nasal Fracture: Management  Always examine for septal hematoma  May progress to abscess formation  resorption of cartilage  severe saddel-nose deformity  Management I & D Placement of temporary drain Intranasal dressings to compress the septal mucosa Antibiotic therapy to decrease risk of infection

14. Nasal Fracture: Management  Repair of Nasal Fracture  Under local anesthesia  After resolution of edema  Reduction techniques (Closed/Open)  Fixation techniques (direct wiring, external suspension, lead plates)  Nasal dressings (internal/ external)  Antibiotic therapy

15. Mandibular Fracture  2 nd most common fracture of facial skeleton  Most commonly affected: condyle & angle  Signs & symptoms 1. Malocclusion of the teeth 2. Tooth mobility 3. Intraoral lacerations 4. Pain on mastication 5. Bone deformity

16. Mandibular Fracture  Initial evaluation:  Fractures of the teeth  Examine dental occlusion  Intraoral examination

17. Mandibular Fracture : Management  Immediate treatment: hygiene, antibiotic, analgesics, stabilization, Figure of eight/ Barton’s bandaging  Splinting  Open reduction  Internal wire fixation  Bone plates  Closed reduction  Application of arch bars  Placement into intermaxillary fixation (IMF)  Antibiotics

18. Zygoma & Orbital Floor Fractures  When untreated, sequelae:  Flattened cheek  Ocular complications (enopthalmos, diplopia)  Zygoma fractures: Signs and symptoms 1. Palpable deformity in the orbital rim 2. Diplopia on upward gaze 3. Hyphesthesia of the cheek 4. Flattening of the lateral aspect of the cheek 5. Periorbital ecchymosis 6. Inferior displacement of the ocular globe

19. Zygoma Tripod Fractures  Tripod fractures consist of fractures through:  Zygomatic arch  Zygomaticofrontal suture  Inferior orbital rim and floor

20.  Fractures of the orbital floor  Restrited upward gaze  Management  Closed/ Open reduction techniques  Orbital floor reconstruction

21. Maxillary Fractures  Among the most severe injuries in the face  Signs & Symptoms 1. Mobility or displacement of the palate 2. Mobility of the nose in assocition with the palate 3. Epistaxis 4. Mobility or displacement of the entire middle third of the face

22. Maxillary Fractures: Classification  Low transverse fracture involving the palate only  Characterized by:  Displacement of maxillary dental arch & palate  Dental malocclusion  AKA Guerin fracture or 'floating palate‘ LE FORT I

23.  aka Pyramidal fracture  Fracture  en bloc of the palate  Mid 1/3 of the face including the nose  Characterized by:  Mobility of the palate & nose  Epistaxis  Dental malocclusion  Retrodispalecement of palate LE FORT II

24.  Most severe injury  Complete disruption of the attachment s of the facial skeleton to the cranium  Transverse fracture  Craniofacial dissociation  Dish faced deformity  Predisposes the patient to CSF rhinorrhea more commonly than the other types LE FORT III

25. Treatment  Open reduction techniques  Firmly fix fractured fragments to intact portions of the skull  Direct wiring, plate stabilization,  Antibiotics

26. Frontal Sinus Fracture  Maybe extremely serious because of cosmetic deformity & CNS involvement  Signs & Symptoms 1. Depression of the anterior table of the frontal sinus 2. Epistaxis 3. Occasional disruption of the posterior table of the frontal sinus with dural rupture & CSF fluid rinorrhea

27.  Escher classification

28.  Management  Open reduction  Internal fixations  Neurosurgical approach

29. Indications for surgical treatment of frontobasal fractures Vital Indications (operate immediately) Life- threatening rise of ICP due to intracranial hemorrhage Bleeding from the nose or sinuses that is refractory to conservative treament Bleeding from an open skull injury that is refractory to conservative treatment Absolute Indications (operate as soon as possible) Open brain injury Dural tear from an indirectly open head injury Penetrating foreign bodies Early complications (meningitis, encephalitis, brain abscess) Late complications ( meningitis, brain abscess, osteomyelitis) Orbital complications

30. Indications for surgery Relative Indications (operate in 1-2 weeks) Displaced bone fragments Fractures involving the drainage tracts of the paranasal sinuses Acute or chronic sinusitis at the time of the injury Post- traumatic sinus inflammation, mucopyocele formation Supraorbital nerve injury due to an adjacent fracture