Maxillofacial Trauma
Etiology and Incidence
- Multisystem injury 20-50%
- Nasal and mandibular fractures most common in community ED’s
- Midface and zygomatic injuries most common in Trauma centers
- 25% of women with facial trauma result of domestic violence
- Incidence of concomitant cervical spine injuries with facial fractures
- Older age, MVC and TBI-higher incidence
- Facial fractures-a distracting injury?
- Carotid artery injury
- Blindness may occur with facial fractures
Emergency Management and Resuscitation
Airway
- Most urgent complication-Airway compromise
- Simple interventions first
- No mandible?
Intubation
- Avoid nasotracheal intubation
- May not want RSI
- Benzodiazepines
- Ketamine
- Etomidate
- Be Prepared and Be Creative
Emergency Management and Resuscitation
Airway Management Options
- Awake intubation
- Laryngeal Mask Airway
- Fiberoptic intubation
- Lateral or semi-prone position
- Percutaneous transtracheal jet ventilation
- Retrograde intubation
- Cricothyroidotomy
Hemorrhage Control
- Rarely develop shock from facial bleeding alone
- Direct Pressure
- LeFort Fractures
- Nasal hemorrhage may require A&P packing
History
- Vision
- Teeth alignment
- Abuse
Maxillofacial Trauma-Physical Exam
Inspection
- Facial elongation
- High grade LeFort Fracture
- Asymmetry
- Deformities and cranial nerve injury
Palpation
- Tenderness
- Step offs
- Facial stability
- Crepitus
- Subcutaneous air
- Cutaneous anesthesia
Periorbital and Orbital Exam
- Perform early
Periorbital and Orbital Exam
- Look for exophthalmos or enophthalmos
- Pupil shape
- Hyphema
- Visual acuity
- Entrapment signs
- Raccoon sign
- Bimanual Palpation Test
Penetrating Injuries
- Occult globe penetration
- Eyelid lacerations
Nose
- Septal hematoma
- CSF Rhinorrhea
Ears
- Subperichondral hematoma
- Hemotympanum
- Battle sign
Oral and Mandibular Exam
- Mandible deviation
- Teeth malocclusion
- Paresthesia
- Tongue Blade Test
– 95% Sensitive
– 65% Specific
Maxillofacial Trauma-Imaging
- Head, chest and abdominal trauma takes precedence
- PE detects up to 90% of fractures
- Plain Films
- CT
– Orbital fractures
– 3D images available
Maxillofacial Trauma-Specific Fractures
Frontal Sinus/Bone Fractures
- Direct blow
- Frequent intracranial injuries
- Mucopyoceles
- Consult with NS for treatment, disposition and antibiotics
Nasoethmoidal-Orbital Injuries
- Lacrimal apparatus disruption
- Bimanual palpation if medial canthus pain
- CT face
Orbital Fractures
- Usually through floor or medial wall
- Enophthalmos
- Anesthesia
- Diplopia
- Infraorbital stepoff deformity
- Subcutaneous emphysema
Orbital Fissure Syndrome
- Fracture of the orbital canal
- Extraocular motor palsies and blindness
- If significant retrobulbar hemorrhage, may need cantholysis to save vision
Zygomatic Fractures
Tripod fracture
- Most serious
- Lateral subconjunctival hemorrhage
- Need ORIF
Arch fracture
- Most common
- Outpatient repair
Maxillary Fractures
- High-energy injury
- 100x gravity
- Malocclusion
- Facial lengthening
- CSF rhinorrhea
- Periorbital ecchymosis
Mandibular Fractures
- Second most common facial fracture
- Often multiple
- Malocclusion
- Intraoral lacerations
- Sublingual ecchymosis
- Nerve injury
Plain films
Panorex
CT
Open Fractures
Pen G or Cleocin
