Assessing the CMF trauma patient

Firdaus Hariri
Oral & Maxillofacial Surgery
Department of Oral & Maxillofacial Clinical Sciences
Faculty of Dentistry, University of Malaya
firdaushariri@um.edu.my
 OUR PRACTICE

Culmination of wisdom from trials and errors

Audits of failures and successes
Careful and mindful reflection of current practice
Willingness to change

Deepak G Krishnan 2013

Systematic assessment of the patient with facial trauma
 Content
1 2 3 4
Assessment Primary Secondary Radiographic
aim
1. Assessment Aim
• Individualizing treatment according to severity
• Identification of trauma degree
Life threatening
Emergency attention
Delayed
Conservative
2. Primary Evaluation
• High index of suspicious
• Primary survey:
• critical areas
• identify all injuries -> immediate intervention
• history
• ATLS
• Specialty evaluation
CMF injuries requiring
immediate attention
Airway
• Etiology :
• laryngotracheal injuries
• foreign body
• fracture fragments
• bleeding from upper source
• Evaluate the need of flexible fiberoptic, tracheostomy

Hemorrhage
• Locate and arrest
• Methods: Compress, ligate/suture, clamp, etc.
CMF injuries requiring immediate attention
Blindness (2 – 5 %)
• Aetiology: Direct injury, retinal vascular occlusion, orbital
compartment syndrome (retrobulbar haemorrhage), retinal
detachment, central vision center
• Direct or indirect mechanism
• Onset: immediate, delayed or post-op
• Comprehensive assessment: Investigations & tests
• Management: observation, corticosteroids, osmotic diuretics, surgical
decompression (or combinations)

Neurological
• Cervical injury (10 – 15 %)
• Neck and spine clinical examination -> maintain spine precaution!
Until cleared
• Investigations: CT and x-rays
 CMF injuries requiring immediate attention
Traumatic Brain Injury
• GCS, intracranial lesion/hemorrhage, midline cranial shift, increased ICP
• Alert of CSF leak + Neuro assessment
3. Secondary Evaluation – CMF

• History
• Signs alert
• Detailed assessment

Assessment of maxillofacial trauma in emergency department

- 754 patients in 3 years, single centre
Arslan et al., 2014
 History
• Complete history
• Specific accident history
From patient (if LOC, altered neurological status -> relative/witness)
Questions
1. How it occur?
2. When it occur?
3. What are the specifics of the injury:
• type of object contacted
• direction from which contact was made
• logistic considerations
4. Was there a loss of consciousness?
5. Latest/updated patient symptoms:
• pain
• altered sensation
• visual changes
• hearing changes
• malocclusion
 Signs Alert
• Diplopia -> orbital fracture
• Numbness:
cheek/maxillary teeth -> zygomaticomaxillary fracture (infraorbital nerve)
chin -> mandible fracture (mental nerve)
• Malocclusion -> mandible or maxillary fracture
• Visual change/blindness -> orbital wall fracture, globe injury
• Loss of hearing or otorrhea -> temporal bone fracture
• Rhinorrhea -> cribiform fracture, frontal sinus fracture
• Trismus -> mandible or zygomatic arch fracture
Detailed CMF
‘Inspection and palpation’

Systematic
• Regional: cranial to caudal
• Region to region
• Ocular
• Intraoral
• Neurological

Signs and symptoms

• Edema
• Ecchymosis
• Facial asymmetry
• Bruising
• Lacerations
• Contour irregularities
• Crepitation
• Pain
• Mobility
Region
Cranium and cranial base
• Scalp, contour irregularities –> skull fracture
• Battle’s sign –> basillar skull fracture
Frontal region
• Swelling
• Depression or crepitus –> frontal sinus fracture (anterior +/or posterior wall)
• Posterior wall –> dura, brain matter, CSF leak, CNS depression
Orbits
• Ecchymosis, edema, emphysema
• Subconjunctival hemorrhage
• Enophthalmos -> ZMC fracture or orbital blowout fracture
• Diplopia + limited upward gaze -> inferior rectus muscle
entrapment
• Infraorbital nerve impairment -> orbital floor fracture
• Palpation of rims -> irregularities, bone deviation, or
impaction.
• Canthal attachments
• Ocular examination
 acuity
 light perception
 motility
 pupil
 conjunctiva
 eyelids
• Fundoscopy
• + ophthalmologist / oculoplastic surgeon
 Ear region
• External ear – hematoma
• External auditory canal and tympanic membrane - blood, CSF, laceration, perforation
• Gross hearing

Nasal region
• Epistaxis
• CSF rhinorrhea
• Swelling
• Nasal airway obstruction
• Septal deviation
• Septal hematoma
• Telecanthus -> nasoorbital-ethmoid fracture
Maxillary region
• ZMC fracture - malar depression or paresthesia
• Trismus - zygomatic arch fracture impinging on
the coronoid process of the mandible
• Le Fort fracture: elongated face, mobile maxilla,
midface instability and malocclusion.
• Maxillary mobility (check: grasping the central
incisors and gently move the maxilla)
Mandible
• Extra-oral:
Lacerations, swelling, ecchymosis, hematoma
Palpation of inferior border of the mandible (symphysis to angle bilaterally): step
deformity, tenderness, asymmetry
Map any neurosensory impairment
Movement of the condyle
Pain of the preauricular area -> condylar fracture.
Mouth opening
classically, deviation on opening is toward the side of the mandibular condyle fracture
limitation of opening
clicking
trismus
• Intra-oral:
 Oral mucosa ecchymosis, gingival tears -> mandibular body or symphyseal fracture
 Changes in occlusion -> displaced fracture, fractured teeth and alveolus)
 Teeth: mobility, absent, avulsed
 Step deformity
 Mandibular fracture instability
 Floor of the mouth
 Active bleeding
 Foreign body: debri, denture, dislodged restorations
 Useful: ask patient to bite -> asking for any difference in occlusion or pain
4. Radiological AOCMF Classification System
Region
• Mandible (code 91)
• Midface (code 92)
• Skull base (code 93)
• Cranial vault (code 94)

Level
• I : Location
• II : Defining fracture location
• III : Subregion
Pearls
• Airway – secure!
• Blood loss
• Cervical spine status
• Clean wound area for better
identification
• Bimanual facial palpation for side-to-
side differences
• Radiographic assessment to assist
diagnosis & treatment plan
• Identify nerve injuries before any local
anaesthesia
• Pre-injury photograph as comparison &
guide
Thank You