Short Case Trauma

TRAUMA
MAXILLOFACIAL

WAODE FITRIANI
K1 A1 14 047
Pembimbing :
dr. Saktrio D Subarno, Sp.BP-RE.

KEPANITERAAN KLINIK ILMU BEDAH

DIVISI BEDAH PLASTIK REKONSTRUKSI DAN ESTETIKA
FAKULTAS KEDOKTERAN UNIVERSITAS HALU OLEO
2019
 • Name : Mrs. S
• Age : 33 Years old
• Sex : Female
IDENTITY • Address : Bunjangga, Morowali
• Occupation : -
• Admission : Octo, 31th, 2019
• Doctor in charge : dr. Saktrio D Subarno, Sp.
BP-RE
 Anamnesis
Chief Complain : face injury
Anamnesis : face injury since 3 days before entering the hospital
MOT : Patient was driving a motorcycle, but suddenly she fall and hit the
asphalt to avoiding people. She wasn’t wearing the helmet at the moment.
Another mechanism is unknown.
HOT :
• There was History of unconciouss
• There was no history of nausea and vomiting.
• There was History of nose bleeding and no history of ear and mouth
bleeding
• There was no history alcohol consumption
• There was previous treatment in RS Morowali : - IVFD RL
- Antibiotic
- Analgetik
- PPI
 A Clear, Cervical Spine Control

Respiratory rate 20x/m,

B spontaneous, thoracoabdominal
type, symetrical, regular
PRIMARY
SURVEY C Blood Pressure 120/80 mmHg
Pulse 90x/m, reguler, strong

Glasgow Coma Scale (E4M6V5),

D isochoric pupil, Ø 2,5 mm/2,5 mm,
Light reflex +/+

E Temperature 36,5OC/Axillary
 Moderate illness, Composmentis,
Good Nourish
Vital Sign
GENERALIZED
STATUS
BP : 120/80 mmHg
HR : 80x/minutes, regular, strong
RR : 20x/minutes, spontaneous,
symmetric, reguler
T : 36,5◦C
 Ears : Normally
Head : Normally
PRESENT Face : Localized state
Neck : Normally
Chest : Normally
STATE Eyes : Localized state
Extremity
Nose : Localized state
Superior : Normally
Mouth : Localized state
Inferior : Normally
 FACIALIS REGION
Inspection
Deformity (-), Sweeling (+) hematoma (-), wound (+)
vulnus eksoriatum 5cmx3xm, active bleeding(-)
Palpation
Tenderness (+), crepitation (+)
LOCALIZED
STATE INTRAORAL REGION
Inspection
Deformity (-), Sweeling (+) hematoma (-), wound (+)
Avulsi labialis superior, active bleeding (-)

Palpation
Tenderness (+)
Step Off

Rima Orbitalis Superior (-)

Rima Orbitalis Inferior (+)
Zygomaticus (+)
Frontonasal (-)
Nasalis (+)
Maxilla (+)
Mandibula (-)
Maloklusi (+)
Avulsi (-)
CLINICAL DOCUMENTATION
 Rountine
Blood
Test
PLAN OF
DIAGNOSTIC
CT-
SCAN
 Laboratory Findings

• WBC 10.08 x103 / µl

• RBC 5.96 x106/ µl
• HB 11.5 g/dL
• PLT 293 x103/ µl
Routine Blood
Test
OPERATION DOCUMENTATION
 Fraktur Blow
DIAGNOSE out+Fraktur Maxilla
Le fort I+ Fr. Nasal
POST OPERATION DOCUMENTATION

• REKONSTRUKSI
ZYGOMAXILLA & ORBITA
FLOOR
• REPOSISI NASAL
 MANAGEMENT
NON
PHARMOCOLOGY
PHARMACOLOGY
• IVFD RL
 Rest • Analgetics inj
 Wound Care • PPI
 Education • Antibiotic inj

CONSULT PLASTIC SURGERY

TINJAUAN PUSTAKA
 DEFINISI
Trauma maksilofasial merupakan cedera yang mengenai
jaringan lunak atau jaringan keras pada area wajah
termasuk daerah frontal, orbital, nasal, zigoma, maksila
dan mandibula.

Trauma jaringan lunak dapat berupa abrasi, kontusi,

laserasi, ataupun luka bakar.

Fraktur maksilofasial dapat berupa fraktur yang mengenai

tulang mandibula, maksila, zigoma, nasal, dan juga
frontal.
 Etiologi
Penyebab terjadinya trauma
maksilofasial adalah kecelakaan lalu lintas,
perkelahian, kecelakaan kerja, cedera
olahraga, gigitan binatang atau manusia,
dan juga akibat terbakar.

Di Indonesia, kecelakaan lalu lintas

merupakan penyebab paling sering pada
trauma maksilofasial.
 Trauma Jaringan Keras
• FRAKTUR DENTOALVEOLAR
Seringkali berhubungan dgn trauma lain seperti
laserasi bibir & mukosa, fraktur maksila &
mandibula

ditandai dengan :
 Pendarahan Intraoral
 Gigi Malposisi
 Maloklusi
 Nyeri
 Perubahan sensasi di gigi
Trauma Jaringan Keras
Fraktur Nasal
• Fraktur nasal merupakan cedera tulang wajah yang
paling umum di jumpai.
• Fraktur nasal biasanya disebabkan oleh trauma
langsung.
• Pada pemeriksaan didapatkan pembengkakan, epitaksis,
nyeri tekan dan teraba garis fraktur. Foto rotgen dari
arah lateral dapat menunjang diagnosis.
 Trauma Jaringan Keras

• FRAKTUR FRONTAL FRAKTUR DASAR ORBITA

• FRAKTUR ZIGOMA FRAKTUR

MANDIBULA
FRAKTUR MAKSILA (Le Fort)
Pemeriksaan Bimanual
 Radiografi

 X Ray Skull
 CT scan
 CT 3 Dimensi
 Treatment three phases.
1. primary phase , survival of the patient by maintenance
airway function, breathing and haemodynamics

2. intermediate phase, supportive line such as antibiotics

prophylaxis , treatment of infections, control of bleeding,
tissue debridement.

3. reconstructive phase. reconstruction of the soft and hard

tissues ,reduction and fixation of bone segments,
reconstruction of the nasolacrimal system, release of scar
tissue, and correction of sensory and motor nerve
dysfunction

26
 Penatalaksanaan fraktur
Prinsip :
 REPOSISI / REDUKSI : mengembalikan
fragmen tulang ke posisi anatomi
 FIKSASI : membuat fraktur tetap dalam posisi
anatomi hingga terjadi penyembuhan
 IMMOBILISASI: Mencegah tulang yang patah
bergerak selama periode penyembuhan
4-6 minggu
 REHABILITASI: Mengembalikan ke fungsi
normal setelah penyembuhan fraktur