Alfred H L Toruan Nugroho S.S M.

Fatikh Nanda

Introduction
Common

with multisystem trauma Require coordinated management by the trauma surgeon and the specialists in otolaryngology, plastic surgery, ophthalmology, and oral and maxillofacial surgery

Maxillofacial Region
Upper

face:

The frontal sinus Brain

Upper

midface:

Orbits Nose Zygomaticomaxillary complex

The

lower face:

Mandible

Problems
Life-threatening

Airway
Vision Nose

& nasoethmoidal fractures CSF rhinorrhea Aesthetics of the face

Fracture Pathophysiology
Maxillofacial

fractures result from blunt or penetrating trauma. Blunt injuries are far more common, including vehicular accidents, altercations, sports-related trauma, occupational injuries, and falls. Penetrating injuries include gunshot wounds, stabbings, and explosions.

Fracture Pathophysiology
Mass,

density, and shape of the striking object, as well as speed of impact, directly affect type and severity of facial injury. The force required to fracture various facial bones may be classified as high impact (greater than 50 times force of gravity [g]) or low impact (less than 50 g).

Fracture Pathophysiology
High-impact

kinetic energy fracture:

100 g 200 g
70 g 100 g

Frontal sinus Orbital rims Mandible Angle Symphisis

Low-impact

forces injure:

Nasal bones 30 g Zygoma 50 g

Frontal Fracture
Frontal

impact May indicate intracranial injury. Associated fractures of the supraorbital ridge, nasoethmoidal complex, and other facial bones also may occur

bone fracture require high-energy

Midface Structure

3 vertical buttresses : nasofrontalmaxillary frontozygomatico maxillary pterygomaxillary 5 weaker horizontal buttresses: the frontal bone nasal bones upper alveolus zygomatic arches infraorbital region

Midface Fractures
Le

Fort I Le Fort II Le Fort III

Le Fort I Fractures
Horizontal

maxillary fracture separates the maxillary process (hard palate) from the rest of the maxilla Extends through the lower third of the septum and involves the maxillary sinus Below the level of the infraorbital nerve no hypesthesia The palatal vault is mobile while the nasal pyramid and orbital rims are stable

Le Fort I Fractures

Le Fort II Fractures
Extends

through the nasofrontal buttress, medial wall of the orbit, across the infraorbital rim, and through the zygomaticomaxillary articulation The nasal dorsum, palate, and medial part of the infraorbital rim are mobile

Le Fort II Fractures
The

inner canthus of the nasal bridge is widened. Extends through the zygoma (near the exit of the infraorbital nerve) hypesthesia is often present Bilateral subcutaneous hematomas are often present.

Le Fort II Fractures

Le Fort III Fractures

= Craniofacial disjunction Extends posteriorly through the ethmoid bones and laterally through the orbits below the optic foramen, through the pterygomaxillary suture into the sphenopalatine fossa The frontozygomaticomaxillary, frontomaxillary, and frontonasal suture lines are disrupted The entire face is mobile from the cranium

Le Fort III Fractures

Midface Fractures
In reality fractures reflect a combination of these three types Signs: Subconjunctival hemorrhage Malocclusion Midface numbness or hypesthesia (maxillary division of the trigeminal nerve) Facial ecchymoses/hematoma Ocular signs/symptoms Mobility of the maxillary complex

Nasal Fracture
Simple

nasal fractures are quite common facial fractures. They must be distinguished from the more serious nasoethmoidal (NOE) fractures. NOE fractures extend into the nose through the ethmoid bones.

Nasal Fracture

Zygoma Fractures
Lateral

blows to the cheek The zygoma is typically displaced inferiorly and medially with disruption of the suture lines between the temporal, frontal, and maxillary bones and the zygoma depression into the maxillary sinus and blood in the sinus cavity
Often impinges on the temporalis muscle below causing trismus

Mandible Fracture
Most

common facial bone fracture

Sites:

Angle Body Condyle

in

most cases 2 sites

Secure the Airway!!!

Mandible

Mandible Fracture

Management
ATLS

Algorhitms Airway obstruction from tissue trauma and edema, foreign debris, or bleeding Subcutaneous emphysema pharyngeal, laryngeal, or tracheal disruption Stridor airway narrowing and possible impending obstruction

Management
Foreign

material finger-swept Blood and secretions suction A jaw thrust, even in the setting of mandibular trauma, and bag-valve mask (BVM) assistance may temporize an airway, especially in the setting of injury to the brain or spinal cord Orotracheal intubation possible midface fractures Nasotracheal intubation the disrupted skull base!!! If intubation proves impossible tracheostomy or cricothyrotomy

Management
The

face is very well vascularized profuse hemorrhage Direct pressure and pressure dressings

Management
Facial

injuries cervical spine and brain trauma Suspected cervical spine injury immobilized on a backboard with a rigid cervical collar GCS<14 CT scan of the head and brain and neurosurgical consultation

Thank You...