Maxillofacial trauma

Most common cause of facial injuries includes motor vehicle or .motorcycle accident, alteracation, athletic, falls and home accident Facial injuries deserve special attention because of their life and aesthetic .significant :Trauma to face is life threathing because of 1. Its area of airway passage mouth and nose! ". Its very vascular area carotid arteries, vertebral arteries! #. It may be associated with other injuries to brain and spine.

Facial injuries classified into:

1. Soft tissue injury. 2. Skeleton injury. 3. Both are affected.

Evaluation and initial management:

1. istory: as$ about the mechanism of injury and if the patient is
unconscious we ta$e the history from witness which includes the mechanism of injury, history of previous medical or surgical disease. !linical examination: the e%amination should be &uic$ and proper.

2.

'egin with overall inspection noting any facial asymmetries, hemorrhage and ecchymosis (eurological e%amination of 1" cranial nerves and sensory e%amination ophthalmic, ma%illary and mandibular! )ll bony surfaces are palpated to assess areas of tenderness, crepitation or any bone defect.

3. "nvestigation: these include general blood e%amination e.g.

*b, +,-, ./0, 1', count. )lso radiological e%amination which include:

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film: which have limited role in the radiological

evaluation of facial trauma. Include: 2ateral s$ull film. +ostanterior view. +anore% radiographs for evaluation of mandible. /ubmentverte% view for 3ygomatic arch. /pinal vertebral 45ray.

B.maxillofacial com%uter tomogra%hy &!'(S!#)*:

which is study of choice for evaluation of most of facial injuries include a%ial and coronal.

Emergency treatment:
1. Maintenance of air+ay: there are many causes of
airway obstruction in facial injuries: 'leeding interferes with respiration. 6isplaced facial fractures. 1hen there is mandibular fracture, the tongue fall bac$ against the pharyn%. Fracture or avulse teeth, vomits, forgien bodies. /welling, edema, hematoma narrowing the airway. .dema tends to develop within 78598 mints. /o patient initially in such case have good airway later it become potentially occluded. The patient place in prone position, and often assures that there is no cervical spine fracture, the nec$ is e%tended. The obstruction by foreign bodies and avulse teeth can be cleared by sweeping fingers deeply into mouth and oral pharyn%. In some cases intubations may be needed, when there is a difficulty in intubations or in patient with significant nec$ swelling and fracture mandible are indication of tracheostomy.

2. !ontrol hemorrhage: although hemorrhage from

facial wound appears alarming, it seldom to be the sole causes of the shoc$, e%cept in case of close range shotgun wound. *emorrhage can be controlled temporarily by direct pressure. In rare situation of uncontrolled hemorrhage from nose or nasopharyn% angiographic emboli3ation.

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3. #s%iration: aspiration of blood, saliva or gastric contents

fre&uently accompanies ma%illofacial injury. It prevented by endotracheal Intubations.

,. Shock: shoc$ is only occasional causes by facial injury alone.

.%tensive facial injury, penetration ocular injury may cause shoc$ by pain. 1hen patient with facial injury is found in shoc$, associated injuries should be suspected.

-. "dentification of other injuries: e.g. abdominal or

thoracic injuries, intracranial injuries. ,ervical spine injuries most injuries to be missed, so patient should be in cautious move and apply cervical collar to patient at site of injury. In case of injury to cranial nerve in face, anesthesia or parasthesia along the course of nerve indicate fracture pro%imally. /uch as loss of sensation in lower lip indicate fracture mandibular body. 1here as facial nerve palsy indicates injury to facial nerve which could be penetrating wounds of parotid or in case of absences of soft tissue injury may suggest temporal bone fracture.

Soft tissue injuries:

)fter life threating problem have been resolved, soft tissue injuries are repaired under local or general anesthesia. /oft tissues injuries can wait without repair up to ": hours without compromising final result provided the bleeding has been controlled and wound is dressed. 6ebridment of wound in face should be conservative. /oft tissue injuries may include: !ontusion: which is busing injury cause by blunt trauma, can be associated with underlying hematoma. #.rasion: This is loss of superficial layer of s$in. $uncture: it may be associated with injury of deep structures. #ccident tattoo: in which small dermis embedded particles. /aceration injury: which most form facial injury and should be repaired in layers. #vulsion injury: in which there is loss of tissues.

!lean cut injury.

S%ecial region consideration:

1. !heek and tem%oral region: high ris$ of injury to facial nerve
and parotid gland.

2. Eyelid injuries: re&uired precise alignment of tarsal plate and lid

margin.

3. /i% injuries: align the whitroll and vermilion border first. ,. Eye.ro+: should be never shaved and must be repaired with
precise attention to its shape and border. Muscles division under brow should always repair to prevent spreading and depression scar. -. )oses: once the bony framewor$ is accurately restored, soft tissues need only to be appro%imated )ccording to anatomical arrangement.

Skeletal injuries:
Maxillary fractures:
2efort fractures first described by anatomist 0ene le fort in 1981.

1. /efort 0 &transverse fracture*: it separated ma%illary alveolus

at the lower margin of pyriform aperture and e%tended through ma%illary sinus. 2. /efort 00 &%yramidal fracture*: e%tended from lefort ; through infrorbital rim and cross the bridge of nose either high or low fashion. 3. /efort 000 &craniofacial disjunction*: the fracture line e%tended across the floor of the orbit and up through nasofrontal area separated the frontal bone from 3ygoma and orbit.

Mandi.ular fractures:
The nec$ of condyle is the most common site fallowed by the angle of mandible< the least common site is the region of canine tooth. Mandibular fracture can be classified according: 1. 1egion of mandi.le: condyle and condylar nec$, ramus, coronoid, angle, body, symphysis. 2. 2%en or closed: depending on whether or not have communication with s$in laceration.

3. according to direction: whether obli&ue, transverse,

comminuted. =sually patient presented with pain, swelling, tenderness and malocclusion. )lso numbness in distribution of mental nereve, bleeding from laceration or from soc$et of tooth, trismus pain on moving the jaw! is noted >n palpation we can feel crepitus, tenderness and when patient to open his or her mouth as$, the jaw deviated toward one side. 0adiographic evaluation of mandible consists of plain film, ,T?/,)(, +anore% e%amination.

3ygomatic fractures:
May result in disarticulation of 3ygomatictemporal and 3ygomaticoma%illary sutures lines.

!linical features:
1. ". #. :. Malar flattening. Infraorbital nerve parasthesia. Tenderness and brusisng. In case of isolated 3ygomatic arch fractures there will be limitation of mandibular range of motion.

Bony or.it fractures:

Inferior and medial wall are most fre&uently involved usually patient presented with diplopia due to injury of muscles or nerve,and also presented with subconjectival hemorrhage. patient could presented with enopthalmus i.e. inward movement of eye globe due to pressure from outside or patient could presented with e%opthalmus which indicated retrorbital hematoma.

)asal .one fractures:

(asal fractures are either laterally or posteriorly displace. /ymptoms and signs: 1. /welling over the e%ternal surface of the nose with swelling in the medial orbital region.
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+ain, respiratory obstruction. ,repitation, nasal deformity, septum deviation. (asal bleedings epista%sis! Mucosal laceration presented with hematoma.

0adiographic e%amination is not absolutely indicated and usually need to e%clude other injuries.

'reatment:
1. /eptal hematoma should be drainage surgically because it causes dissolution of the cartilage because of pressure necrosis. ". ,orticosteroids are used to minimi3e edema and facilitated evaluation of fracture reduction. #. epista%sis can be arrest by: 0aise head up. ,old bandage. +ressure on nose e%ternally. >r by internal pressure by gau3e with -aseline. :. Management of fractures should done immediately before a significant edema is developed or after edema is resolve usually after @5A days during this period the patient should give steroid and antibiotics. Management of fractures by refracturing the bone and reposition of nasal bone in proper architecture, and with used of internal pac$s with jipsona used e%ternally to hold the bone. Internal pac$s are removed in day #, while e%ternal jipsona are removed in 1" days.