Maxillofacial Trauma

Joe Lex, MD, FACEP, FAAEM

Temple University School of Medicine Philadelphia, PA USA

Joseph.Lex@TUHS.Temple.edu

Lecture Outline
Emergency management Facial exam Fractures
Major Minor

Soft tissue injuries Unusual injuries

Causes of Mortality
Acute
Airway compromise Exsanguination Associated intracranial or cervicalspine injury

Delayed
Meningitis Oropharyngeal infections

Epidemiology
Estimated 3,000,000 facial trauma cases per year in USA Estimated 40 to 50% of motor vehicle victims have facial injury No uniform reporting or registry of cases

Functions of Face
Respiratory upper airway Visual Olfactory Mastication Cosmetic Communication Individual recognition

Management Sequence
Airway control / immobilize cervical spine Bleeding control Complete the primary survey Secondary survey
Consider NG or OG tube placement

Management Sequence
Plain radiographs if fractures suspected CT if suspect complex fractures

Management Sequence
Repair soft tissue immediately if no other injuries Delay soft tissue repair until patient in OR if surgery for other injuries necessary

Initial Management
Step 1: Airway control Oxygen for all patients May need to keep patient sitting or prone Stabilize C-spine early Large bore (Yankauer) suction available

Initial Management
Step 1: Airway control Orotracheal intubation preferred over nasotracheal if possible midfacial fracture and invasive airway needed Combitube, retrograde wire, or cricothyroidostomy if unable to orotracheally intubate

Initial Management
Step 2 : Bleeding control Can be major threat to life Use universal precautions Direct pressure dressings initially Contraindicated: blind vessel clamping

Initial Management
Step 2 : Bleeding control Rapid nasal packing may be necessary
Be sure blood is not just running down posterior pharynx

Initial Management
Step 2 : Bleeding control Rarely: emergent cutdown and ligation of external carotid artery needed to prevent exsanguination Note: Although shock in facial trauma patient is usually due to other injuries, it is possible to bleed to death from a facial injury

Airway Compromise
Blood in airway Debris in airway
Vomitus, avulsed tissue, teeth or dentures, foreign bodies

Pharyngeal or retropharyngeal tissue swelling Posterior tongue displacement from mandible fractures

Secondary Survey
Scalp Check for lacerations, hematomas, stepoffs, tenderness Bleeding maybe brisk until sutured Can use stapler for rapid closure

Secondary Survey
Ears Examine pinnae, canal walls, tympanic membranes Suction gently under direct vision if blood in canal Put drop of canal fluid on filter paper for ring sign CSF leak Assess hearing

Secondary Survey
Eyes Pupils, anterior chamber, fundi, extraocular movements Conjunctivae for foreign bodies Palpate orbital rims
No globe palpation if suspect penetration

Secondary Survey
Eyes Lid injury can leave cornea exposed
Use artificial tears or cellulose gel

Secondary Survey
Overall facial appearance Assess for symmetry, deformity, discoloration, nasal alignment Palpate forehead & malar areas

Secondary Survey
Nose Check septum for hematoma & position Check airflow in both nares Palpate nasal bridge for crepitus Check fluid on filter paper for ring sign (for CSF leak)

Secondary Survey
Mouth Check occlusion Reflect upper & lower lips Check Stenson's duct for blood Palpate along mandibular and maxillary teeth (be careful !)

Secondary Survey
Mouth Palpate along exterior of mandible Pull forward on maxillary teeth

Secondary Survey
Neurologic Skin fold symmetry at rest Motor: each division of CN-VII Sensation: 3 divisions of CN-V Sensation on tongue Gag reflex

Fracture Classification
Major Lefort I, II, III Mandibular Minor Nasal Sinus wall Zygomatic Orbital floor Antral wall Alveolar ridge

Forces Required
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures 100 g Supraorbital rim fractures 200 g

Lefort Fractures
Lefort fractures can coexist with additional facial fractures Patient may have different Lefort type fracture on each side of the face

Differentiating Leforts
Pull forward on maxillary teeth Lefort I: maxilla only moves Lefort II: maxilla & base of nose move: Lefort III: whole face moves:

Lefort I: Nasomaxillary
Horizontal fracture extending through maxilla between maxillary sinus floor & orbital floor
Crepitus over maxilla Ecchymosis in buccal vestibule Epistaxis: can be bilateral Malocclusion Maxilla mobility

Lefort I: Nasomaxillary
Closed reduction Intermaxillary fixation: secures maxilla to mandible May need wiring or plating of maxillary wall and / or zygomatic arch Antibiotics: anti-staphylococcal

Lefort II: Pyramidal

Subzygomatic midfacial fracture with a pyramid-shaped fragment separated from cranium and lateral aspects of face

Lefort II: Pyramidal

Signs & symptoms Midface crepitus Face lengthening Malocclusion Bilateral epistaxis Infraorbital paresthesia Ecchymoses: buccal vestibule, periorbital, subconjunctival

Lefort II: Pyramidal

Hemorrhage or airway obstruction may require emergent surgery Treatment can often be delayed till edema decreased

Lefort II: Pyramidal

Usually require Intermaxillary fixation Interosseous wiring or plating of infraorbital rims, nasal-frontal area, & lateral maxillary walls May need additional suspension wires Antibiotics

Lefort III
Craniofacial dissociation Bilateral suprazygomatic fracture resulting in a floating fragment of mid-facial bones, which are totally separated from the cranial base

Lefort III
Signs and Symptoms Face lengthening: caved-in or donkey face Malocclusion: open bite Lateral orbital rim defect Ecchymoses: periorbital, subconjunctival

Lefort III
Signs and Symptoms Bilateral epistaxis Infraorbital paresthesia Often medial canthal deformity Often unequal pupil height

Lefort III
Usually associated with major soft tissue injury requiring emergent surgery for bleeding control Surgery can be delayed till edema resolves Intermaxillary fixation

Lefort III
Transosseous wiring or plating
Frontozygomatic suture Nasofrontal suture May need extracranial fixation if concurrent mandibular fracture

Antibiotics

Forces Required
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures 100 g Supraorbital rim fractures 200 g

Mandible Fractures
Airway obstruction from loss of attachment at base of tongue >50 % are multiple Condylar fractures associated with ear canal lacerations & high cervical fractures High infection potential if any violation of oral mucosa

Mandible Fractures
Signs and symptoms Malocclusion Decreased jaw range of motion Trismus Chin numbness Ecchymosis in floor of mouth Palpable step deformity

Mandible Fractures
Tongue blade test: have patient bite down while you twist. If no fracture, you will be able to break the blade.

Mandible Fractures
Treatment Prompt fixation: intermaxillary fixation (arch bars), +/- body wiring or plating

TMJ Dislocation
Can occur from direct blow to mandible Can occur spontaneously from yawning or laughing Mandible dislocates forward & superiorly Concurrent masseter & pterygoid spasm

TMJ Dislocation
Symptoms Patient presents with mouth open, cannot close mouth or talk well Can be misdiagnosed as psychiatric or dystonic reaction

TMJ Dislocation
Treatment Manual reduction: place wrapped thumbs on molars & push downward, then backward Be careful not to get bitten Usually does not require procedural sedation or muscle relaxants

Forces Required
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures 100 g Supraorbital rim fractures 200 g

Nasal Bone Fractures

Often diagnosed clinically: x-ray not needed Emergent reduction not necessary except to control epistaxis Usually do not need antibiotics Early reduction under local anesthesia useful if nares obstructed

Nasal Bone Fractures

Nasal septal hematoma: incise & drain, anterior pack, antibiotics, follow-up at 24 hours Follow-up timing for recheck or reduction:
Children: 3 to 5 days Adults: 7 days

Forces Required
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures 100 g Supraorbital rim fractures 200 g

Zygomatic Fractures
Tripod (tri-malar) fracture Depression of malar eminence Fractures at temporal, frontal, and maxillary suture lines

Zygomatic Fractures
Isolated arch fracture Less common Shows best on submental-vertex xray view Painful mandible movement Usually treat with fixation wire if arch depressed

Zygomatic Fractures
Tripod S & S Unilateral epistaxis Depressed malar prominence Subcutaneous emphysema Orbital rim stepoff Altered relative pupil position Periorbital ecchymosis Subconjunctival hemorrhage Infraorbital hypoesthesia

Forces Required
Nasal fracture 30 g Zygoma fractures 50 g Mandibular (angle) fractures 70 g Frontal region fractures 80 g Maxillary (midline) fractures 100 g Mandibular (midline) fractures 100 g Supraorbital rim fractures 200 g

Supraorbital Fractures
Frontal sinus fracture Often associated with intracranial injury Often show depressed glabellar area If posterior wall fracture, then dura is torn

Supraorbital Fractures
Ethmoid fracture Blow to bridge of nose Often associated with cribiform plate fracture, CSF leak Medial canthus ligament injury needs transnasal wiring repair to prevent telecanthus

Orbital Fractures
Blow out fracture of floor Rule out globe injury
Visual acuity Visual fields Extraocular movement Anterior chamber Fundus Fluorescein & slit lamp

Orbital Fractures
Symptoms and signs Diplopia: double vision Enophthalmos: sunken eyeball Impaired EOMs Infraorbital hypesthesia Maxillary sinus opacification Hanging drop in maxillary sinus

Orbital Fractures
Diplopia with upward gaze: 90%
Suggests inferior blowout Entrapment of inferior rectus & inferior oblique

Diplopia with lateral gaze: 10%

Suggests medial fracture Restriction of medial rectus muscle

Orbital Fracture: Treatment

Sometimes extraocular muscle dysfunction can be due to edema and will correct without surgery Persistent or high grade muscle entrapment requires surgical repair of orbital floor (bone grafts, Teflon, plating, etc.)

Facial Soft Tissue Injuries

Before repair, rule out injury to:
Facial nerve Trigeminal nerve Parotid duct Lacrimal duct Medial canthal ligament

Remove embedded foreign material to prevent tattooing

Facial Soft Tissue Rules

For lip lacerations, place first suture at vermillion border Never shave an eyebrow: may not grow back If debridement of eyebrow laceration needed, debride parallel to angle of hairs rather than vertically

Facial Soft Tissue Rules

Antibiotics for 3 to 5 days for any intraoral laceration (penicillin VK or erythromycin) and if any exposed ear cartilage (anti-staphylococcal antibiotic) no evidence Remove sutures in 3 to 5 days to prevent cross-marks

Facial Soft Tissue Rules

Most face bite wounds can be sutured primarily Clean facial wounds can be repaired up to 24 hours after injury Place incisions or debridement lines parallel to the lines of least skin tension (Lines of Langer)

Questions??

Summary
Assess ABC's first Do complete exam as part of secondary survey Obtain standard X-rays and / or CT scan as indicated Decide if specialist referral and / or operative repair indicated

Summary
Arrange followup after repair to assess for delayed complications or cosmetic problems