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Maxillofacial

Trauma
Andi Siswandi, MD
Surgeon
Malahayati University, Medicine Faculty

Etiology and Incidence


Multi system injury 20-50%
Nasal and mandibular fractures most common

in community EDs
Midface and zygomatic injuries most common
in Trauma centers
25% of women with facial trauma result of
domestic violence
Incidence of concomitant cervical spine
injuries with facial fractures

Etiology and Incidence


Older age, MVC and TBI-higher incidence
Facial fractures-a distracting injury?
Carotid artery injury
Blindness may occur with facial fractures

Maxillofacial Trauma

Emergency Management and


Resuscitation
Airway
Most urgent complication-Airway compromise
Simple interventions first
No mandible?

Intubation
Avoid nasotracheal intubation
May not want RSI
Benzodiazepines
Ketamine
Etomidate
Be Prepared and Be Creative

Emergency Management and


Resuscitation
Airway Management Options
Awake intubation
Laryngeal Mask Airway
Fiberoptic intubation
Lateral or semi-prone position
Percutaneous transtracheal jet ventilation
Retrograde intubation
Cricothyroidotomy

Emergency Management and


Resuscitation
Hemorrhage Control
Rarely develop shock from facial bleeding alone
Direct Pressure
LeFort Fractures
Nasal hemorrhage may require A&P packing
History
Vision
Teeth alignment
Abuse

Maxillofacial Trauma-Physical Exam


Inspection
Facial elongation
High grade LeFort Fracture
Asymmetry
Deformities

and cranial nerve injury

Palpation
Tenderness
Step offs
Facial stability

Crepitus
Subcutaneous air
Cutaneous anesthesia

Maxillofacial Trauma-Physical Exam


Periorbital and

Orbital Exam
Perform early

Professional Lid
Retractor

Maxillofacial Trauma-Physical Exam


Periorbital and Orbital Exam
Look for exophthalmos or enophthalmos
Pupil shape
Hyphema
Visual acuity
Entrapment signs
Raccoon sign

Bimanual Palpation Test

Maxillofacial Trauma-Physical Exam


Penetrating Injuries
Occult globe penetration
Eyelid lacerations
Nose
Septal hematoma
CSF Rhinorrhea
Ears
Subperichondral hematoma
Hemotympanum
Battle sign

Maxillofacial Trauma-Physical Exam


Oral and Mandibular Exam
Mandible deviation
Teeth malocclusion
Paresthesia
Tongue Blade Test
95% Sensitive
65% Specific

Maxillofacial TraumaImaging
Head, chest and abdominal trauma takes

precedence
PE detects up to 90% of fractures
Plain Films
CT
Orbital fractures
3D images available

Maxillofacial Trauma-Specific
Fractures
Frontal Sinus/Bone Fractures
Direct blow
Frequent intracranial injuries
Mucopyoceles
Consult with NS for treatment, disposition and
antibiotics
Nasoethmoidal-Orbital Injuries
Lacrimal apparatus disruption
Bimanual palpation if medial canthus pain
CT face

Maxillofacial Trauma-Specific
Fractures
Orbital Fractures
Usually through
floor or medial wall
Enophthalmos
Anesthesia
Diplopia
Infraorbital stepoff
deformity
Subcutaneous
emphysema

Maxillofacial Trauma-Specific
Fractures
Orbital Fissure Syndrome
Fracture of the orbital canal
Extraocular motor palsies and blindness
If significant retrobulbar hemorrhage, may
need cantholysis to save vision

Zygomatic Fractures
Tripod fracture
Most serious
Arch fracture
Lateral subconjunctival hemorrhage
Most common
Need ORIF
Outpatient repair

Tripod Fracture

Maxillofacial Trauma-Specific
Fractures
Maxillary Fractures
High-energy injury
100x gravity
Malocclusion
Facial lengthening
CSF rhinorrhea
Periorbital ecchymosis

LeFort Fractures

Maxillofacial Trauma-Specific Facial


Fractures
Mandibular Fractures
Second most common facial

fracture
Often multiple
Plain films
Malocclusion
Panorex
Intraoral lacerations CT
Sublingual ecchymosis
Nerve injury
Open Fractures
Pen

G or Cleocin

Body

30-40 %

Angle

25-30 %

Condyle

15-17 %

Symphysis

7-15 %

Ramus

3-9 %

Alveolar

2-4 %

Coronoid
Process

1-2 %

Lecture Questions
1. What portion of the mandible is most

commonly fractured?
Ramus
b. Coronoid process
c. Body
d. Angle
e. Symphysis
a.

2. Orbital fractures can cause all of the following

except:
Blindness
b. Motor palsies
c. Facial anesthesia
d. Enophthalmos
e. Hyphema
a.

3. Which of the following is/are true regarding

maxillary fractures?
Only minimal force necessary
b. Rarely cause CSF rhinorrhea
c. May cause facial lengthening
d. Usually the only sustained injury
e. All of the above are true
a.

4. The best modality for diagnosing an orbital

or facial fractures is
Plain films
b. MRI
c. CT
d. Ultrasound
e. Osteopathic palpation
a.

5. Which statement below is correct?


a. Midface fractures usually have minimal
morbidity
b. The tongue blade test is quite sensitive in
assessing need for mandibular xrays
c. The bimanual nasal exam is crucial in possible
medial orbital wall fracture
d. Midface fracture is an indication for
nasotracheal intubation and RSI is often needed
in these patients
c, e, c, c, b

THANK YOU