Maxillofacial trauma: Difference between revisions
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===Orbital===
===Orbital===
*See [[Orbital Fracture]]
*See [[Orbital Fracture]]
===Zygoma===
*Must distinguish zygomatic arch fx from zygomaticomaxillary (tripod) fx
**Tripod fx = fx of zygomatic arch, lat and inf orbital rims, lat wall of maxillary sinus
*Exam
**Flattening of malar eminence
**Eye findings
***Eye may appear to tilt (pulling of lateral canthus)
***Subconjunctival hemorrhage
**Trismus (masseter spasm or impingement of temporalis muscle or coronoid process)
***Palpate posterior surface of arch for tenderness/loss of space compared to other side
*Management
**Facial CT
*Disposition
**Isolated zygomatic arch fx: discharge
**Tripod fx w/ loss of vision or displacement: admit for IV abx and sx
===Midface===


==Disposition==
==Disposition==

Revision as of 21:36, 16 July 2011

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 Fx
    • 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

  • Frontal sinus fractures
    • 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 fractures
    • 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 Fx
    • Clincal diagnosis (does NOT require xrays)
    • Drain septal hematomas and f/u w/ ENT in 7-10 day
  • Zygomatic arch fracture
    • Unlikely isolated
  • Tripod Fracture
    • Fx through:
      • 1. Inf orbital rim
      • 2. lateral orbital wall
      • 3. Fx/dislocation of zygomatic arch
    • Must r/o associated ocular injuries
    • Usually requires admission and surgical repair

Fracture Types

Frontal Bone

  • Requires high-energy
    • Must rule-out TBI, additional fx, and cervical spine injury
  • Assess sinus involvement:
    • Crepitus
    • Laceration over fracture site is typical
  • Imaging
    • Head CT indicated if suspect fracture
      • Assess anterior and posterior tables
        • Through and through fx require sx to prevent pneumocephalus, CSF leak, infection
  • Management
    • Sinus involvement?
      • If yes then give 1st gen cephalosporin or amoxicillin clavulanate
    • Isolated anterior table fx?
      • D/C w/ facial surgeon f/u
    • Depresed fx?
      • Admit for IV abx and operative repair

Orbital

Zygoma

  • Must distinguish zygomatic arch fx from zygomaticomaxillary (tripod) fx
    • Tripod fx = fx of zygomatic arch, lat and inf orbital rims, lat wall of maxillary sinus
  • Exam
    • Flattening of malar eminence
    • Eye findings
      • Eye may appear to tilt (pulling of lateral canthus)
      • Subconjunctival hemorrhage
    • Trismus (masseter spasm or impingement of temporalis muscle or coronoid process)
      • Palpate posterior surface of arch for tenderness/loss of space compared to other side
  • Management
    • Facial CT
  • Disposition
    • Isolated zygomatic arch fx: discharge
    • Tripod fx w/ loss of vision or displacement: admit for IV abx and sx

Midface

Disposition

  • 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

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