Maxillofacial Trauma

Question 1

What radiographic scans should you have for mandibular fractures?

Answer 1

1. Mandibular series
2. Townes view
3. Panoramic
4. Occlusal
5. CT Scan

Question 2

What are some clinical examinations you can do for mandibular fractures?

Answer 2

1. Palpation of inferior border and condolences
2. Mandibular movements
3. Occlusion
4. Bi-manual mobility
5. Neurosensory testing

Question 3

Where is the most frequent mandibular fractures? Second and third?

Answer 3

1. Body of the mandible (30-40%)
2. Angle
3. Condyle

Question 4

Name the anatomical classifications of mandibular fractures

Answer 4

Angle
Sub condylar
Body
Condolences
Symphysis
Alveolar
Coronoid

Question 5

What is a simple fracture?

Answer 5

A fracture that is not open to skin or mucosa

Question 6

What is a compound fracture?a

Answer 6

A fracture that is open to the skin/mucosa – to the external surface

Question 7

What is a comminuted fracture?

Answer 7

A fracture that has multiple segments

Question 8

What is a greenstick fracture?

Answer 8

Fractures which only have one cortex involved

Question 9

What is the treatment of nasal-orbital-ethmoid fractures?

Answer 9

Overall you obviously want to restore form and function.

There should be proper reduction of nasal fractures, correction of medial cantonal ligament, and correction of lacrimal system injuries

Question 10

What should you assume if the medial canthal ligament is injured?

Answer 10

That there is damage to the lacrimal system

Question 11

What is epiphora?

Answer 11

It is an overflow of tears – indicating damage to lacrimal duct/system

Question 12

How should you treat external bleeding (hemorrhaging on site)

Answer 12

Pressure and gain access to the vascular system with IV catheters – you want to give ringer’s lactate (electrolytes), saline, and transfusion.

Question 13

When should you suspect C-spine injury?

Answer 13

When there is an injury above the clavicle, injury causing unconsciousness, and high speed injury

Question 14

What is the proper initial procedure in dealing with C-spine injury

Answer 14

If C-spine injury suspected:

• avoid movement of the spinal columns
• lateral C-spine radiograph + CT of C-spine

Question 15

What are the general descriptions of early and definitive care

Answer 15

Early care is after stabilization of emergency care – you want to do a head and neck exam where you inspect, palate, and radiograph

Definitive care is treating soft tissue injuries:
- contusions
- abrasions
- lacerations
And consider possible structures that could be effected:
- lacrimal systems
- parotid duct
- facial nerve

Question 16

What are the 2 most common fractures of the face

Answer 16

First is nose

Second is the mandible

Question 17

What types of fractures are most common in the mandible?

Answer 17

1. Body
2. Angle
3. Condolences

50% of mandibular fractures are multiple

Question 18

What are the clinical signs and symptoms of mandibular fractures

Answer 18

• Tenderness/pain
• Malocclusion
• Ecchymosis in floor of mouth
• mucosal lacerations
  Step defects inferior
• CN V3 disturbances
• trismus
• bi-manual mandibular mobility
• deviation of mandibular movements

Question 19

What are the radiographs you want to take when dealing with mandibular fractures?

Answer 19

• mandibular series
• Townes view
• panoramic
• occlusal
• CT scan
• 3-D reconstruction

Question 20

What is a favorable mandibular fracture? Unfavorable fracture?

Answer 20

Muscles:

• lateral pterygoid - depresses mandible
• massager + medial pterygoid + temporalis - elevates mandible

Favorable fracture:
- when the muscles associated with fracture brings the fractures closer together

Unfavorable fracture:
- when the muscles separate fracture segments further

Question 21

What is a Lefort I fracture?

Answer 21

It is a fracture above the apices of the teeth but below the zygomatic bone. It goes through the nose and the tuberous its of the maxilla into the pterygoid – there is a disarticulation of the maxillary from the rest of the facial skeleton

Question 22

What is a Lefort II fracture?

Answer 22

It is a fracture that goes through part of the orbital bone –> frontonasal junction –> part of the orbital bone on the opposite side

Question 23

What is a Lefort III fracture?

Answer 23

It is a fracture that goes through the entire orbit to –> frontonasal junction –> the orbit of the opposite side

Question 24

How do you diagnose Lefort I fractures?

Answer 24

You can tell by the direction of force you apply on the maxilla – the maxilla can be displaced posteriorly and inferiorly.

Mobility of the maxilla can also be seen by grasping of maxillary incisors

There is hypoesthesia of the infraorbital nerve

Malocclusion

Question 25

How do you treat Lefort I fractures?

Answer 25

You always want to align occlusion for any fracture 1. Reduction and anatomic relalignment of maxillary buttresses to re-establish: - anterior projection - transverse width occlusion (align occlusion) 2. Restoration of occlusion using IMF 3. Internal fixation using mini plate fixation

Question 26

How do you diagnose Lefort II and III

Answer 26

Radiographs are very important because clinical evaluation only provides a rough impression due to swelling hiding the underlying bony structures: 1. CT scans (axial and coronal) 2. Plain film radiographs Clinically you should see: - bilateral periorbital edema and ecchymosis - step deformities palates infraorbital and nasofrontal area - CSF rhinorrhea - epistaxis

Question 27

How do you treat Lefort II and III

Answer 27

TEAM APPROACH (neurosurgery, ophthalmology, ENT, plastic surgery, OMFS) Start: 1. Establishment of correct occlusion (can estimate preliminary fix with wires before this step) 2. Correct reconstruction of outer facial frame for proper facial dimensions 3. Correct position for nasoethmoidal complex 4. Re-establish correct intercanthal distance 5. Infraorbital rims fixated 6. Orbit is reconstructed 7. Occlusion unit with IMF is fixated

Question 28

In facial examination of maxillofacial trauma patient, you notice that he has a Lefort II fracture. Clinically there is discharge from nose/ear -- what is logical to suspect?

Answer 28

It is logical to suspect CSF leak because it is associated with a base of the skull fracture -- this mostly occurs in Lefort II or III fractures because it can go through cribiform plate

Question 29

How do you diagnose nasal-orbital-ethmoid fractures?

Answer 29

You perform: 1. Ophthalmalogic evaluation - document visual acuity - pupillary response to light 2. Neurological examination - frontal lobe contusion - Glasgow coma scale (increase in ICP and need for monitoring) Radiographically (remember -- Lefort II and III) - CT scans (axial and coronal) - plain films (less effective because it fails to demonstrate the degree and location of fractures secondary to overlapping of bony architecture) Clinically: - comminuted with posterior displacement - widened nasal bridge - splayed nasal complex - epistaxis - peri-orbital edema and ecchymosis - subconjunctival hemorrhage