Management of Midfacial Fractures Flashcards
(97 cards)
1
Q
the ___________ is largely responsible for an individuals unique appearance
A
midfacial skeleton and overlying soft tissue
2
Q
within the realm of facial trauma_________, because of its location and projection within the facial sphere is highly susceptible to injury
A
the midface
3
Q
traumatic midface fractures can have a profound effect on a patient’s:
A
quality of life and the consequences might be functional, aesthetic or a combo of both
4
Q
depending on the severity of the trauma a patient can have:
A
a change in vision, the ability to communicate and properly masticate
5
Q
the main skeletal components that comprise the midface include the:
A
- orbit
- maxilla
- nasal bones
- zygomatic complex arch
- naso orbital ethmoid complex
6
Q
the main goal for management of midface fractures is:
A
functional and cosmetic rehabilitation and for this precise anatomic reduction is key
7
Q
sound anatomic knowledge of the mid facial skeleton is critical such as:
A
orbit, maxillary, nasal bones, zygomatic complex and NOE complex
8
Q
the paired nasal bones articulate with the:
A
frontal bone and the maxilla
9
Q
what makes nasal bone fractures the most common facial fracture
A
the central location of the nose and its prominence on the facial skeleton
10
Q
nasal bone fractures have been estimated to occur in about _____ of patients with facial fractures
A
39%
11
Q
what forms the midline support structure of the nose
A
nasal septum
12
Q
the bony septum of the nasal septum consists of:
A
the perpendicular plate of the ethmoid bone posterosuperiorly and the vomer posteroinferiorly
13
Q
the posterior cartilage articulates with the:
A
ethmoid and the vomer
14
Q
what forms the bony floor of the nasal cavity
A
the maxilla and the palatine bones
15
Q
isolated nasal bone fractures are usually treated by:
A
closed reduction
16
Q
the ______ and ______ are designed to reduce the displaced septum and the impacted nasal bones
A
Asch and Walsham forceps
17
Q
the ________ is the central bony unit of the face and shares skeletal articulations with many of the bones in the craniofacial skeleton
A
the maxilla (paired embryologically)
18
Q
the maxilla functionally acts with the:
A
palatine bones
19
Q
the maxilla is less dense and houses the:
A
paranasal sinuses
20
Q
it has been suggested that the anatomy of the maxilla offers an evolutionary advantage in which:
A
crumple zones potentially absorb the energy of blunt trauma, preventing direct transmission of forces to the neurocranium
21
Q
the position of the zygoma in the midface contributes to:
A
the anterior posterior and transverse projection of the facial skeleton
22
Q
trauma to the midface often involves fractures of the:
A
zygoma and its articulations
23
Q
the zygoma is classically described as a:
A
quadrilateral bone that articulates with the temporal, sphenoidal, frontal, and maxillary bones, thus creating 4 different sutures
24
Q
why is the term TRIPOD fracture a misnomer
A
there are 4 fracture points with ZMC fractures
25
what do the zygomas do
protect the orbit and define the malar prominence
26
what are the bones that form the orbit
frontal, zygomatic, ethmoid, lacrimal, maxilla, palatal, sphenoid
27
the floor of the orbit slopes into:
medial wall
28
what is the floor of the orbit made of
maxillary bone and part of zygoma bounded laterally by the inferior orbital fissure and small part of the ethmoid bone
29
what nerve enters the orbit and where
optic nerve (CN-II) superio-medially to the true apex
30
theres ________- anatomical separation between the floor and medial wall of the orbit
no
31
what is the shape of the orbit
a four sided pyramid or cone
32
the NOE complex is composed of a confluence of four paired bones
- lateral nasal bones (2)
- frontal processes of the maxilla (3)
- lacrimal bones (4)
- lamina papyracae of the ethmoid bones (5)
33
what is the area of strength of the midface
vertical and horizontal buttresses
34
what are the area of weaknesses of the midface
sutures and air filled cavities
35
what are the buttresses
functionally, through composed of thin bone,the bony part of the midface has focal areas of strength referred to as buttresses
36
what are the maxillofacial buttresses
- vertical maxillary buttress
- horizontal maxillary buttress
37
what are the buttresses
areas of primary stability within the facial skeleton and help in the accurate reduction of bony fractures and serve as primary areas for the placement of rigid fixation
38
what are the medial butresses
the nasomaxillary, the lateral zygomaticomaxillary, and posterior pterygomaxillary butresses
39
what is the purpose of the vertical butresses
to withstand occlusal or masticatory forces
40
what do the vertical maxillary buttresses dp
radiate forces cephalically from the maxilla to the base of skull
41
what is the cosmetic function of the vertical maxillary butress
they serve to establish vertical height of the face
42
what bones make up the horizontal maxillary buttresses
- supraorbital rims
- infraorbital rims
- alveolar process of the maxilla
43
what is the function of the horizontal butresses
to reinforce the vertical butresses
44
the _________ which supports the nasomaxillary and zygomaticmaxillary vertical buttresses
frontal bar is the thick area of the frontal bone
45
below the eyes, you have the area of the ______ which supports the same vertical butresses as the frontal bar
infraorbital rim
46
the _______ is the inferior most part of the horizontal buttress of the midface
maxillary alveolar ridge
47
accurate anatomical reduction of the facial buttresses is important in order to reproduce the
original width, height and projection
48
repair of the vertical facial buttresses restores:
vertical height and increases resistance to occlusal forces
49
stabilization of the frontozygomatic and zygomaticomaxillary buttresses with rigid fixation can:
restore the projection in the middle third of the face and in combination with maxillomandibular fixation of an intact stable mandible it can also restore the posterior height of the facial skeleton
50
what is the epidemiology of the mid facial fracture
- male: females 4:1
- predominantly in 20's or 30's
- cause: MVA >altercation> fall
- site: nasal > zygoma > other
- in altercations left zygoma fractured more often
51
what are the history for midface fractures
- mechanism of injury
- events leading up to injury
- time of injury
- associated medical problems
- allergies
- medications
52
what does the physical exam for midface fractures consist of
- can be diffiuclt in trauma pt
- dont forget trauma CABs (ATLS)
- occlusion, trismus, stability, asymmetry, extraocular movements, visual acquity, V2 paresthesia, step offs, laceration and ecchymosis, CSF leaks
53
what are the common clinical findings
- facial asymmetry
- peri-orbital ecchymosis
- subconjunctival hemorrhage and chemosis
- widened intercanthal distance
- crepitation and step deformity
- maxillary mobility and malocclusion
- rule out Battle's sign (mastoid ecchymosis- skull base fracture)
54
______ is the modality of choice for radiographic exam
CT
55
________ is indicated with orbital injuries
ophthalmologic consultation
56
what are the indications of orbital injuries
- visual acquities
- pupillary function
- extraocular movements
- visual field testing
- funsoscopic exam
57
what are the patterns of fractures of mid-facial skeleton
- le fort fracture (maxillary fracture)
- orbital wall fractures
- zygomatic complex fracture
- naso-orbito-ethmoid fracture
58
what is a Le lefort I fracture and what bones are involved
horizontal fracture through the maxilla above the level of the nasal floor and alveolar process
- piriform rims
- anterior maxilla
- zygomatic buttresses
- pterygoid plates
59
what are the signs and symptoms of Le Fort I fracture
- slight swelling of upper lip
- ecchymosis in upper lip sulcus
- hematoma intra orally over zygoma in palate
- disturbed occlusion
- mobility of teeth of the involved segment of maxilla
- combination of soft tissue laceration
- impacted type of fracture is often not mobile and teeth cusps may be damaged
60
what is another name for the Le Fort II fracture and what is it
- pyramidal
- separation of NF suture, medial orbital walls (lacrimal bone), inferior orbital floor and rim (adjacent to infraorbital canal and foramen) anterior maxilla below zygomatic buttress and pterygoid plates
- separation of the block from the base of skull is completed via the nasal septum and may involve the floor of the anterior cranial fossa
61
what is another name for the LeFort III Fracture and what is it
- craniofacial dysfunction
- separation of NF suture, medial orbital walls (involve the depth of the ethmoid bone and cribiform plate, pass below optic foramen and cross the inferior orbital fissure), inferior orbital floor, lateral orbital wall, ZF suture, zygomatic arch, root of pterygoid plate
62
what are the signs and symptoms of Le Fort II and III fractures
- bilateral peri-orbital ecchymosis
- bilateral subconjunctival hemorrhage
- CSF leak rhinorrhea
- retropositioning of the maxilla with anterior open bite
- mobility of the upper jaw
63
describe orbital wall (floor) fractures
- internal orbital fractures
- in conjunction with other facial fractures
- as isolated type (blow out fracture)
64
describe orbital floor fractures
- rule out entrapment of inferior rectus muscle
- diplopia
- peri orbital ecchymosis
- subconjunctival ecchymosis
- vertical dystopia
- enophthalmos
65
what is the clinical exam for orbital floor fractures
- subconjunctival ecchymosis may indicate orbital fracture
- forced duction test is used to identify any entrapment of the inferior rectus muscle
66
the malar bone represent a strong bone on fragile supports, and it is for this reason that:
through the body of the bone is rarely broke, the four processes- frontal, orbital, maxillary and zygomatic are frequent sites of fracturee
67
what are the signs and symptoms of the zygomatic complex fractures
- flattening of the malar prominence
- flattening over the zygomatic arch
- deformity at the orbital margin
- deformity at the zygomatic buttress of the maxilla
- periorbital ecchymosis and edema
- pain and tenderness on palpation
- trismus
- paresthesia
- epistaxis
- subconjunctival ecchymosis
- unequal pupillary levels
- diplopia
- enophthalmos
68
______ may indicate zygoma fracture
midface asymmetry
69
what is the clinical exam for zygomatic complex fracture
palpate for any bony steps and look for asymmetry
70
what is a type I NOE fracture
- involves a signle, non comminuted, central fragment, without medial canthal tendon disruption
71
describe a type II NOE fracture
- involve communication of the central fragment without medical canthal tendon disruption
72
describe a type III fracture
result in severe central fragment communication with medial canthal tendon avulsion
73
what telecanthus
naso-orbital-ethmoid fractures
74
what is the normal intercanthal distance
- white males: 33-34mm
- white females: 32-33mm
75
what is abnormal intercanthal distance
more than 35mm
76
telecanthus is increased distance between:
medial canthi
77
what is the physical exam for naso-orbital ethmoid fractures
- flattened nasal dorsum and septal deviation
- lack of skeletal support on palpation of nose
- rounding of medial canthus
- CSF leak
- epiphora
- rule out frontal sinus injury
- associated ocluar injury
- enophthalmos
- diplopia
- entrapment
- vertical dystopia
- loss of globe integrity
78
what are the goals of midface fracture treatment
- restore: bone anatomy, dental occlusion, function, normal nerve function
- prevent infection
- relieve pain
79
what is the main goal of midface fractures
- functional and cosmetic rehabilitation and for this precise anatomic reduction is key
80
what factors can affect management strategies
- multi trauma
- concomitant mandible injury
81
what is the order of repairs
from bottom to top and outside to inside
82
what is the surgical treatment of midfacial fractures
- surgical approach (intra and extra oral)
- reduction of fracture
- immobilization/fixation of fracture
83
what is the intraoral approach to expose midfacial fracture site
buccal sulcus
84
what is the extraoral approach to expose midfacial fracture site
- lateral brow
- inferior orbital rim/floor access (transconjunctival, subciliary, infraorbital)
- coronal/hemicoronal
85
describe the buccal sulcus approach
- leave mucosa to sew to later
- identify and preserve V2
86
describe the lateral brow incision
- avoid shaving brow hairs
- goal is the ZF suture
87
what is the definitive treatment for midface fractures
- reduction of fracture
- manual manipulation
- use of dis-impaction forceps
- temporal (Gilles- extra oral): for reduction of ZMC arch and ZMC arch complex fractures
- intra oral: for reduction of ZMC arch and ZMC arch complex fractures
88
what are disimpaction forceps used for
may be needed to restore facial dimensions before fixation
89
what are the principles of midface fractures
- rehabilitation of occlusal relationship
- reduction of bone segment
- fixation of fractures segments
90
midfacial fractures associated with:
occlusal abnormalities
91
what are the options for fixation of midfacial fractures
- direct intraosseous wiring
- open reduction and internal fixation - ORIF
- suspension wiring technique
92
what are the different ORIF of midface fractures
- ORIF of LeFort I Fracture
- ORIF of naso-orbital ethmoidal fracture (NOE)
- ORIF of zygomatic complex fracture (ZMC)
93
goal is functional and cosmetic reduction to:
restore form and function
94
precise _____ restoration is key
anatomic
95
treatment is:
tailored to each individual
96
knowledge of _______ will lead to superior results
anatomy and techniques
97
