Maxillofacial trauma: Difference between revisions

(Text replacement - "Fx" to "fracture")
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===Pediatric Considerations===
===Pediatric Considerations===
*Cricothyrotomy is contraindicated in patients <8yr old
*Cricothyrotomy is contraindicated in patients <8yr old
*Maxillary sinuses do not develop until 6 yr old (reduces midfacial fx)
*Maxillary sinuses do not develop until 6 yr old (reduces midfacial fracture)
*Pediatric orbital floor is more pliable, more likely to lead to entrapment
*Pediatric orbital floor is more pliable, more likely to lead to entrapment
*Mandible fx requires prompt referral (1-2d) due to rapid bone remodeling
*Mandible fracture requires prompt referral (1-2d) due to rapid bone remodeling


==Clinical Features==
==Clinical Features==
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*Numbness
*Numbness
**Check supraorbital, infraorbital, and mental nerves
**Check supraorbital, infraorbital, and mental nerves
*Assess Le Fort by rocking hard palate w/ one hand while stabilizing forehead w/ other
*Assess Le Fort by rocking hard palate with one hand while stabilizing forehead with other
===Eye===
===Eye===
*Exam
*Exam
**Bird's eye view for exophthalmos w/ retrobulbar hematoma
**Bird's eye view for exophthalmos with retrobulbar hematoma
**Worm's view for endophthalmos (blow-out fx) or malar prominence flattening (zygoma fx)
**Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture)
*Acuity
*Acuity
*[[Diplopia]]
*[[Diplopia]]
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**Monocular diplopia suggets lens dislocation
**Monocular diplopia suggets lens dislocation
*Extraocular motion
*Extraocular motion
**Limitation on upward gaze occurs w/ fx of inf and medial orbital wall
**Limitation on upward gaze occurs with fracture of inf and medial orbital wall
*Pupil
*Pupil
**Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test)
**Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test)
*Pressure (only if r/o globe rupture)
*Pressure (only if rule out globe rupture)
**Check in patients w/ exophthalmos, afferent nerve defect or e/o retrobulbar hematoma
**Check in patients with exophthalmos, afferent nerve defect or evidence of retrobulbar hematoma
*Fat through wound = septal perforation
*Fat through wound = septal perforation
*Raccoon eyes
*Raccoon eyes
===Nose===
===Nose===
*Crepitus over any facial sinus suggests sinus fx
*Crepitus over any facial sinus suggests sinus fracture
*[[Septal Hematoma]]
*[[Septal Hematoma]]
*Make sure simple nasal fx isn't a complex naso-orbito-ethmoid injury
*Make sure simple nasal fracture isn't a complex naso-orbito-ethmoid injury
===Ears===
===Ears===
*[[Auricular Hematoma]]
*[[Auricular Hematoma]]
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*Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury
*Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury
*[[Mandible Fracture]]
*[[Mandible Fracture]]
**Place finger in auditory canal while patient opens and closes jaw to detect condyle fx
**Place finger in auditory canal while patient opens and closes jaw to detect condyle fracture
**Tongue blade test
**Tongue blade test
***95% Sn for no fx if can bite down hard enough to break it when twisted by examiner  
***95% Sn for no fracture if can bite down hard enough to break it when twisted by examiner  
**Jaw deviation due to mandible dislocation or condyle fx
**Jaw deviation due to mandible dislocation or condyle fracture
***Chin will point away from dislocation, towards a fracture
***Chin will point away from dislocation, towards a fracture
*Malocclusion occurs in mandible, zygomatic, and Le Fort fx
*Malocclusion occurs in mandible, zygomatic, and Le Fort fracture
*Lacerations and mucosal ecchymosis suggests mandible fx
*Lacerations and mucosal ecchymosis suggests mandible fracture


==Differential Diagnosis==
==Differential Diagnosis==
{{Maxillofacial trauma DDX}}
{{Maxillofacial trauma DDX}}


==Diagnosis==
==Evaluation==
*Suspect midface fx > facial CT
===Workup===
*Suspect orbital floor fx > orbital CT
*Suspect midface fracture > facial CT
*Suspect mandibular fracture
*Suspect orbital floor fracture > orbital CT
**Mandibular series
*Suspect mandibular fracture > CT face
***Body fx > oblique view
 
***Angle/symphysis fx > PA view
==Management==
***Condyle fx > AP axial (Towne's) view
*Treat underlying process/diagnosis
*Plain Films
**Water's view
***Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
**Bucket handle view
***zygomatic arches


==Disposition==
==Disposition==

Revision as of 18:49, 21 November 2017

Background

Prehospital Care

  • Assess patients ability to speak and protect the airway before and frequently during transport
  • Hematomas can significantly distort pharyngeal and facial anatomy making intubation or cricothyroidotomy difficult
  • Increased jaw mobility from a mid face fracture may help with intubation
  • Penetrating trauma to the lower third of the face frequently requires intubation or a surgical airway[1]
  • Place a protective shield over an eye suspected to have a ruptured globe
  • Patients should remain upright or reverse trendelenberg if there is oropharyngeal and nasal bleeding to avoid aspiration especially if placed in cervical protection
  • Temporizing hemostasis with oral and nasal packing in an intubated patient may help with persistent bleeding
  • Transport all avulsed pieces of the face including ears and nose

Pediatric Considerations

  • Cricothyrotomy is contraindicated in patients <8yr old
  • Maxillary sinuses do not develop until 6 yr old (reduces midfacial fracture)
  • Pediatric orbital floor is more pliable, more likely to lead to entrapment
  • Mandible fracture requires prompt referral (1-2d) due to rapid bone remodeling

Clinical Features

Face

  • Numbness
    • Check supraorbital, infraorbital, and mental nerves
  • Assess Le Fort by rocking hard palate with one hand while stabilizing forehead with other

Eye

  • Exam
    • Bird's eye view for exophthalmos with retrobulbar hematoma
    • Worm's view for endophthalmos (blow-out fracture) or malar prominence flattening (zygoma fracture)
  • Acuity
  • Diplopia
    • Binocular diplopia suggests entrapment of EOM
    • Monocular diplopia suggets lens dislocation
  • Extraocular motion
    • Limitation on upward gaze occurs with fracture of inf and medial orbital wall
  • Pupil
    • Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test)
  • Pressure (only if rule out globe rupture)
    • Check in patients with exophthalmos, afferent nerve defect or evidence of retrobulbar hematoma
  • Fat through wound = septal perforation
  • Raccoon eyes

Nose

  • Crepitus over any facial sinus suggests sinus fracture
  • Septal Hematoma
  • Make sure simple nasal fracture isn't a complex naso-orbito-ethmoid injury

Ears

Oral

  • Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury
  • Mandible Fracture
    • Place finger in auditory canal while patient opens and closes jaw to detect condyle fracture
    • Tongue blade test
      • 95% Sn for no fracture if can bite down hard enough to break it when twisted by examiner
    • Jaw deviation due to mandible dislocation or condyle fracture
      • Chin will point away from dislocation, towards a fracture
  • Malocclusion occurs in mandible, zygomatic, and Le Fort fracture
  • Lacerations and mucosal ecchymosis suggests mandible fracture

Differential Diagnosis

Maxillofacial Trauma

Evaluation

Workup

  • Suspect midface fracture > facial CT
  • Suspect orbital floor fracture > orbital CT
  • Suspect mandibular fracture > CT face

Management

  • Treat underlying process/diagnosis

Disposition

See Also

References

  1. Hollier L. et al. Facial gunshot wounds: A 4-year experience. Journal of Oral and Maxillofacial Surgery. 2011: 59:277-282