1. Intern’s Hour Maxillofacial Trauma Preceptor: Dr. Germar BLOCK R

2. The Case  24-year-old male who sustained traumatic injuries during a soccer game  DOI: 3/18/2010  TOI: 7 AM  POI: soccer field  MOI:  Few hours PTC, the patient, a soccer goalkeeper, attempted to recover a loose ball when he was struck in the face by an opponent’s knee. After contact, the patient fell to the ground on his left side in a side-lying position.

3. Review of Systems  (-) LOC  (-) seizure  (+) headache  (+) dizziness  (-) vomiting  (-) rhinorrhea/ epistaxis  (-) otorrhea  (-) dyspnea  (-) chest pain  (-) abdominal pain  (-) urinary and bowel changes

4. Physical Examination  VS: BP 130/80, HR 86, RR 20, afeb  HEAD and NECK:  (+) R periorbital edema with subconjunctival hemorrhage, OD  R facial swelling and tenderness  (+) crepitus on R maxillary area  (+) upper lip laceration  (-) malocclusion, able to open mouth to 4 fingerbreaths

5. Physical Examination  HEART  AP, DHS, NRRR, apex beat @ 5 th ICS LMCL, (-) murmur  CHEST and LUNGS  ECE, CBS, (-) crackles/ wheezes  ABDOMEN  Soft, flat abdomen, NABS, (-) tenderness  EXTREMITIES  PNB, FEP, (-) cyanosi/ edema

6. Physical Examination  NEURO  GCS 15 (E4V5M6), oriented to 3 spheres  CN intact  Motor strength 5/5 on all extremities  (-) sensory deficit  DTRs 2+, (-) Babinski  Supple neck

7. Assessment  Multiple Injuries 2⁰ to ---  1. R periorbital contusion with subconjunctival hemorrhage of the R eye  2. t/c R maxillary fracture  r/o intracranial injury

8. Course  Upon arrival at the ER,  A: with the athlete in the supine position, an attempt to open the airway using a modified jaw-thrust maneuver was performed.  B: the breathing can be compromised as a result of blood from ongoing facial bleeding. After blood was quickly cleared from the face, the source of bleeding was identified in the upper lip, which had sustained a complete through-and-through laceration. Direct pressure was immediately applied.  C: blood pressure was noted to be normal, cervical spine was secured

9. Diagnostics  CBC  Blood type  PT/PTT  Na, K, Cl, BUN, Crea

10. Diagnostics  Towne’s, Water’s, SMV  radiographs of the chest, cervical spine  The radiographs revealed no evidence of vertebral fracture or pulmonary disease  computed tomography (CT) scans of the brain and face

11. CT scan  The CT scans identified fractures of the anterior, posterior, and medial walls of the right maxillary sinus. A small pocket of air was identified in the right infratemporal fossa, suggesting an occult fracture of the lateral wall of the right maxillary sinus. The initial facial CT scan also suggested a fracture of the floor of the right orbit.  The cranial CT showed no evidence of skull fracture or intracranial injury.

12. Final Diagnosis  Multiple Injuries 2⁰ to ---  1. R periorbital contusion with subconjunctival hemorrhage of the R eye  2. R maxillary fracture

16. 1. Fractures of the Nasal Pyramid 2. Fractures of the Central Midface  Le Fort Fractures

17. 3. Fractures of the Lateral Midface 4. Fractures of the Frontal bone 5. Fractures of the Anterior Skull Base  Escher Classification

18. 6. Fractures or dislocation of the mandible

19.  Sports  Vehicular Accidents  Mauling  Women – consider the possibility of domestic violence

20.  Patients with severe facial trauma:  multisystem trauma  potential for airway compromise  concurrent brain injury  cervical spine injuries  blindness

21.  Primary Survey  Airway  Breathing  Circulation  Secondary Survey

22. Airway:  Chin lift.  Jaw thrust.  Oropharyngeal suctioning  Manually move the tongue forward  Maintain cervical immobilization

23.  Avoid nasotracheal intubation  Adverse effects: ▪ Nasocranial intubation ▪ Nasal hemorrhage   cricothyroidotomy

24. Circulation:  Direct pressure  Anterior and posterior nasal packing  Packing of the pharynx around ET tube

25.  Place, Time, Date, Mechanism of injury  Detailed description of the circumstances surrounding the injury  Allergies, other medical problems, medications, tetanus immunizations

26.  Questions:  Was there LOC, nausea/vomiting, headache? (Head Trauma related questions)  How is your vision?  Hearing problems?  Is there pain with eye movement?  Are there areas of numbness or tingling on your face?  Able to bite down without any pain?  Is there pain with moving the jaw?

27. Inspection  Open wounds for foreign bodies  Facial asymmetry  Nose for deviation, widening of bridge  Nasal septum for septal hematoma, CSF or blood  Ears for blood or CSF  Malocclusion

28.  Raccoon eyes Inspection  Battle’s sign

29. Inspection  Otorrhea, Rhinorrhea  Halo Sign  Not sensitive or specific but can be used as a preliminary test for CSF in blood  Dipstick  Beta transferrin

30. Palpation  Palpate the entire face.  Supraorbital and Infraorbital rim  Zygomatic-frontal suture  Zygomatic arches  Nose - crepitus, deformity and subcutaneous air  Zygoma along its arch and its articulations with the maxilla, frontal and temporal bone  Mandible for tenderness, swelling

31.  Intraoral examination:  Inspect the teeth for malocclusions, bleeding  Manipulation of each tooth  Check for lacerations  Mandibular movements

32. Ophthalmologic exam  Visual acuity  Pupils for shape and reactivity  Eyelids for lacerations  Extra ocular muscles  Palpate around the orbits

33.  Examine and palpate the exterior ears  Otoscopic examination  Look for lacerations  TM rupture

34.  Plain films  Confirm suspected clinical diagnosis  Determine extent of injury  Document fractures  CT scan

35.  ATS, TeAna  Thorough evaluation of all wounds  All foreign bodies must be removed  Debridement  Suturing of lacerations as needed  Minimize scarring  Antibiotics

36.  Most common bone injury in the face  Open or closed  Signs  Depression or displacement of nasal bones  Edema of nose  Epistaxis  Fracture of septal cartilage with displacement or mobility  Crepitus on palpation

37.  All nasal injuries should be evaluated for septal hematoma  Untreated- result in septal necrosis and saddle nose deformity  Can become infected- result in a septal abscess

38.  Radiographs:  Lateral projection  Treatment:  Surgical  After reduction, nasal cavities should be packed – “internal splinting”

39.  Le Fort’s classification  Le Fort I (transverse maxillary)  Le Fort II (pyramidal)  Le Fort III (craniofacial dysjunction)

40.  Low transverse fracture of maxilla involving palate  Facial edema  Mobility of hard palate and upper teeth  Malocclusion

41.  Pyramidal fracture with detachment of maxilla  Facial edema  Epistaxis  Bilateral periorbital edema and ecchymosis

42.  Complete disruption of attachments of facial skeleton to cranium  Movement of all facial bones in relation to the cranial base with manipulation of the teeth and hard palate  Open patient’s mouth and grasp the maxilla arch  Place the other hand on the forehead  Gently move back and forth, up and down - check for movement of maxilla

44.  Massive edema with facial elongation, flattening – “Dish faced deformity”  Epistaxis and CSF rhinorrhea  Motion of the maxilla, nasal bones and zygoma

45.  Open reduction and intermaxillary fixation should be performed to establish correct occlusion  Followed by rigid fixation at the piriform rims and zygomaticomaxillary buttress.

46.  The zygoma has 2 major components:  Zygomatic arch  Zygomatic body  Two types of fractures can occur:  Isolated Arch fracture -most common  Tripod fracture - most serious

47.  Palpable bony defect over the arch  Flattening of the cheek  Pain in cheek and jaw movement  Limited mandibular movement

48.  Radiographic imaging:  Submental view “bucket handle view” - Arches may not be seen in usual views (anterior, lateral)  Treatment:  Symptomatic - surgical

49.  Tripod fractures consist of fractures through:  Zygomatic arch  Zygomaticofrontal suture  Inferior orbital rim and floor  Symptoms  Periorbital edema  Sensory disturbances along the infraorbital nerve

50.  Waters  Caldwell  Submental  Coronal CT  Treatment:  Symptomatic - surgical

51.  Isolated fracture of the orbital floor with partial herniation of orbital contents  Facial asymmetry  Enophthalmos  Diplopia on upward gaze- impingement of inf. Rectus  Check for sensory disturbances – cheek, upper lip, lateral nasal wall

52.  CT scan  Management:  Indicated for displaced fractures or for symptomatic fractures

53.  Uncommon  Depression of anterior table of frontal sinus  Intracranial injuries  Dural tears  Epistaxis  CSF rhinorrhea (disruption of posterior table of frontal sinus with dural rupture)

54.  Radiographs:  Facial views should include: ▪ Waters ▪ Caldwell ▪ lateral projections  Caldwell view best evaluates the anterior wall fractures

55.  Cranial CT with bone window  Frontal sinus fractures.  Orbital rim and nasoethmoidal fractures  R/O brain injuries or intracranial bleeds

56.  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.

57.  Associated with intracranial injuries  Orbital roof fractures  Dural tears  Mucopyocoele  Epidural empyema  CSF leaks  Meningitis

59.  2nd most commonly fractured facial bone  Signs and symptoms  Malocclusion of teeth  Tooth mobility  Intraoral lacerations  Pain on mastication  Bone deformity

60.  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

61.  Radiographs:  Panorex  Plain view: PA, Lateral and a Townes view

62. Treatment:  Nondisplaced fractures:  Analgesics  Soft diet  Dent/ORL surgery referral  Displaced fractures, open fractures and fractures with associated dental trauma  Urgent oral surgery consultation  All fractures should be treated with antibiotics and tetanus prophylaxis.

63.  Antibiotics  Pain management  Suture the upper lip laceration.  The facial fractures are nondisplaced and do not require surgery. These facial fractures should be followed for evidence of healing.