Maxillofacial trauma: Difference between revisions
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==Diagnosis==
==Diagnosis==
*Always ask about vision
===History===
*Evaluate for:
*Evaluate for:
**Facial numbness
**Facial numbness
***Check supraorbital, infraorbital, and mental nerves
**Misalignment of teeth
**Misalignment of teeth
**Diploplia (monocular vs binocular)
**Vision changes


*Anesthesia of upper lip and/or maxillary teeth may be 2/2 infraorbital nerve injury from orbital blowout or orbital rim fx
===Inspection===
*Bird's eye view for exophthalmos w/ retrobulbar hematoma
*Worm's view for endophthalmos (blow-out fx) or malar prominence flattening (zygoma fx)
*Raccoon eyes and Battle Sign
===Palpation===
*Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury
*Assess Le Fort by rocking hard palate w/ one hand while stabilizing forehead w/ other
===Eye===
*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
===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
===Oral===
*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


*Physical Exam
==Imaging==
**Jaw deviation - chin will point away from dislocation and towards a fracture
**Best way to palpate the mandibular condyles is to place a finger in the external auditory canal and press down while pt opens and closes mouth.
 
Imaging
*Suspect midface fx > facial CT
*Suspect midface fx > facial CT
*Suspect orbital floor fx > orbital CT
*Suspect orbital floor fx > orbital CT
*Suspect mandibular Fx
*Suspect mandibular Fx
**Mandibular series
**Mandibular series
**Body fx > oblique view
***Body fx > oblique view
**Angle/symphysis fx > PA view
***Angle/symphysis fx > PA view
**Condyle fx > AP axial (Towne's) view
***Condyle fx > AP axial (Towne's) view
*Plain Films
*Plain Films
**Water's view
**Water's view
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==DDx==
==DDx==
*Frontal sinus fractures
*Frontal sinus fractures
**If ant wall Fx need CT to evaluate posterior wall (75% have both walls Fx)
**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 IVABx
**Need neurosurg or ENT for posterior wall fx since many need surgery and IV abx
*Naso-ethmoid fractures
*Naso-ethmoid fractures
**Diffuse tearing and increased intercanthal distance are suggestive
**Diffuse tearing and increased intercanthal distance are suggestive
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*Nasal Fx
*Nasal Fx
**Clincal diagnosis (does NOT require xrays)
**Clincal diagnosis (does NOT require xrays)
**Drain septal hematomas and f/u with ENT in 7-10 days
**Drain septal hematomas and f/u w/ ENT in 7-10 day
*Zygomatic arch fracture
*Zygomatic arch fracture
**Unlikely isolated
**Unlikely isolated
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==See Also==
==See Also==
*[[Mandible Fx]]
*[[Mandible Fx]]
*[[Orbital Blowout Fx]]
*[[Orbital Blowout Fx]]
==Source==
Tintinalli's


[[Category:Trauma]]
[[Category:Trauma]]

Revision as of 20:32, 16 July 2011

Diagnosis

History

  • Evaluate for:
    • Facial numbness
      • Check supraorbital, infraorbital, and mental nerves
    • Misalignment of teeth
    • Vision changes

Inspection

  • Bird's eye view for exophthalmos w/ retrobulbar hematoma
  • Worm's view for endophthalmos (blow-out fx) or malar prominence flattening (zygoma fx)
  • Raccoon eyes and Battle Sign

Palpation

  • Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury
  • Assess Le Fort by rocking hard palate w/ one hand while stabilizing forehead w/ other

Eye

  • 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

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

Oral

  • 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

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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