Ch 34 Facial Trauma Flashcards
14 facial bones
nasal
lacrimal
zygomatic
inferior nasal conchae
vomer
maxilla
mandible
8 cranial bones
ethmoid
parietal
teporal
frontal
ethmoid
occ
Bones of the orbit
frontal bone
shenoid
zygomatic
lacrimal
maxilla
palatine
optic
Fx orbit
zygoma
palatine
maxilla
Fx of orbit which m starts here
inferior rectus
Superior orbital fissure CN?
CN 3, 4, 6
CN 5: jobs
m mastication
sensation
V1, V2 and V3
Branches of CN7
cervical
zygomatic
temporal
buccal
marginal mandibular
Denver Criteria RF
High E teauam mech
complx skull fracture
sev TBI
seatblt
thoracic injuries
scalp degloving
severe facial #
mandible fracture
hanging or clothes line neck injury
TBI or thacic injury
blunt cardiac rupture
first rib fracture
Clinical signs and sx consistent with + Denver criteria
arterial hemorrhage
cervical bruit
expanding cervical hematoma
focal neurological deficit
neuro finding not explained by CT
Ischemic stroke on secondary CT
Seidel sign
+ globe rupture: a clear band appears below the suspected injury site, indicating a leak. This is caused by the fluorescein diluting in the leaking fluid
Frontal bone injury site concerning features, imaging, management
sign trauma mech, ams, tender ndema over fronta lbone, CSF rhinorr
ct scan imaging (head/cspine, max face)
ATLS consultation specialty
Orbital injury site concerning features, imaging, management
**NEED TO ADD
Rhinorrhea concerning for ?
dural tear
Frontal sinus fracture requires what kind of exam?
ocular
Anterior table fracture: how to manage
admit
sinus prec: no nose blow, cough and sneeze muth open, hob 30deg
+ ctx 1-g IV q24h
+/- surg
Posterior table surgery # - consult?
Nsx
as can have dural tear
need abx
Superior orbital fissure syndrome
fracture of SOF =
fixed dilated pupil, upper lid ptosis, loss of corneal reflex, opthalmoplegia
*CN not involved - this is orbital apex syndrome (decr vis acuity)
Orbital blowout fracture - what is this?
inferomedial wall of orbit #
Orbital blowout fracture - on exam?
visual acuity, pupillary exam, slit lamp with florescien, ocular pressure test
Globe rupture concerning pupil change?
tear drop
Orbital blowout fracture - Retrobulbar hematoma concern?
high iop, enopathlmos
Oculocardiac reflex - bradycardia
nausea syncope
Retrobulbar hematoma tx
lateral canthotomy + methypredn 30mg then load then in 2H 15mg/kg q6h, acetazolamide and mannitol
EOM - if upward gaze diplopia - concern what m?
inferior oblique m or inferior rectus mm
unconscious - forced adduction
Nasal fracture - need to r/o ?
septal hematoma
drain
rhino rocket/anterior pack
abx
Naso orbital ethmoid complex # - see?
loss of dorsonasal prominence
periorbital and glabellar ecchymosis
telecanthus - inner canthus’ >35mm (N 30-32)
+ bow string: lateral traction –> concern if can move whole thing
Cribiform plate # may see?
rhinorrhea
Naso orbital ethmoid complex - plan for management
nsx
CSF leak watch
optho to r/o rlobe
abx - clinda and 3rd gen cephalosprin
Zygomaticomaxillary complex #/Tripod fracture - which 4 bones are fractures?
zygo arrticlates with frontal, sphenoid maxillary and temporal bone
Zygomaticomaxillary complex #/Tripod fracture - findings
enopthalmos
periorbital and subjunctival hemorrhages
flattening of midface/malar asymm
trimus
inferior displ of globe and lateral canthus -> diplopia
infra orbital injury paresthesia of cheek/upper lip/atn incisors/alar of nose
intraoral hematoma
Zygomaticomaxillary complex #/Tripod fracture - gold standard imaging
ct
Zygomaticomaxillary complex #/Tripod fracture - nondisplaced vs displaced #
non - home, soft diet x6 weeks, elevive repair 1-14d
displaced or trismus = surg
Le Fort # - I
floating palate
horizontal maxilla fracture, alveolar ridge, lateral nose and inf wall of maxillary sinus
Le Fort # - II
floating maxilla
pyramidal # with teeth at base and nasofrontal suture at apex
fracture arch through posterior alveolar ridge, lateral walls of maxillary sinuse, inferior orbital rim and nasal bones
Le Fort # - III
floating face ie craniofacial dysfunction
transverse # through nasofrontal suture, maxillo frontal suture, orbital walls and zygomatic arch
Le Fort # needs what involved to call lefort?
sphenoid bone pterygoid plate involvement
Mandible fracture: uni fracture - what to do?
look for another spot! U shaped
Mandible fracture: assessment?
malocclusion
trismus
crepitus/bony step off
mandibular instability/lacs
inatraoral ecchymosis/loose teeth
open bite vs deviation on jaw
Mandibular # management
early split wires/bar - comminuted dusplaced/injfected = soon
Ellis classifcation for dental alveolar trauma
I fracture in enamel - tooth white
II fracture reaches dentin - tooth yellow
III fracture into pupl (tooth red)
If newly missing teeth, how to find?
CXR
bronchoscopically in airway
cxr below diaphragm is fine
Reimplanatation of teeth
amox clav
tetanus
Lip lacs tx
approx each layer full thickness
m - monocryl 3.0, 4-0, vircyl 3-0
skin - nylon/prolene 6-0, 7-0
mucosa - chromic 3-0, 4-0
Auricular hematoma
drain with 18g needle or scalpel
TMJ reduction
syringe technique - between teeth and rolle AP
two fingers in and front of mandible and
Name the bones of the anterior facial skeleton
frontal bone
nasal bone
zygotmata
maxillary bones
mandible
Musculature of face innervated by which 2 CN?
9
10
Just inferior to ext auditory canal, which CN innervates most anterior m layer (including facial expression)?
CN7
Name 3 divisions of CN5
v1 - opthalmic upper 1/3 face
v2 - maxillary sensory innerv midface, including infraorbital nerve
v3 - mandibular - sensation to lower 1/3 face
What are Langer lines?
lines of facial expression
What forms the lateral wall and lateral floor of the orbit?
zygoma
Bony orbit composed superiorly of __ bone
frontal
What forms the medial floor and anteromedial wal of orbit?
maxilla
What forms the medial wall of the orbit?
lacrimal and ethmoid bones
Where is the orbit most delicate and vulnerable to injury?
lacrimal and ethmoid bones at medial wall
What/where is alar cartilage?
entrances to symmetric mucosa lined nares (ie nose)
What lies above and crossing midline, behind nasal bridge to form superior portion of nasal septum and cribriform plate?
ethmoid bone
What makes up the inferior portion of the bony septum?
vomer
What forms the posterior floor and hard palate of the nose?
palatine process of maxillary bone
What is the first sinus to become aerated and when?
birth - ethmid and mastoid antrum
Which sinus forms at 3yoa?
SPHENOID
and rest of mastoid
Which sinus forms at 6yoa?
frontal
which sinus forms at 10yoa?
maxillary
What is the usual occlusion position of teeth with mouth closed?
lower row lie just internal to upper row
When does the body of the mandible fuse at the symphysis?
2yo
What is the joint between the TMJ?
hunge
between meniscus and condyle
and between meniscus and temporal bone - sliding joint, allowing translation
Vasculature of the face - all comes from the external carotid artery except for ? artery
opthalmic
What 3 arteries of the face come from the external carotid artery?
facial
superficial temporal
maxillary
What are the course of lacrimal ducts?
superior and lateral to globe, secrete tears through ductules into folds of conjunctiva –> medially into puncta of lacrimal canaliculi and drains into lacrimal sac, then via nasolacrimal duct into nasopharynx
Name 3 salivary system glands
parotid
sublingual
submandibular glands
Parotid duct is superficial to __ m and drains via __ duct
masseter
stensen
Where is the sublingual gland?
floor of mouth and drain into mouth via ductules
surround the ducts draining submandibular glands
Where is the submandibular gland?
folded around mylohoid m portion that lies within floor of mouth and portion lies external to it
What is important to determine facial injuries?
mechanism
blunt or penetrating
assoc injuries to head/spine/vasculature
Pe of the face post trauma: general recommendations
Start with airway
secondary survey - facial sturcture and function:
- bony prominences - pain, motion, crepitus, step off
- upper incisors pull forward for LeFort I if upper alveolar ridge moves vs midface (type II) vs entire face (type III)
- wounds
- zygoma from above
-fluorescein for abrasion
-EOM
What orbit fractures may result in diplopia on upward gaze, and why?
blow out #
inferior rectus m or anesthesia or midface/upper lip in V2 distribution
Oral examination after trauma: what should this entail?
inspect palate, teeth, tongue, gums and palpation with gloved finger
if maximal incisor opening <5cm - mandibular # may be present
Trismus finding after facial injury, indicates?
fracture or sign hematoma
What is Rosen’s best recommendation for test of malocclusion?
asking the patient themselves if appropriate to do so
What is the tongue blade test for malocclusion?
grasp and hold tongue blade between teeth while examiner pulls gently
How to determine if Stenson duct is injured? Why is this important?
opening of duct opp secondd molar examined for bleeding when gland compressed
surgical repair to prevent formation of cutaneous fistula
What is key on nasal examination after trauma?
tender
creptius
abnormal movement
ea nare tested for sniffle
presence of septal hematoma
For facial wounds, when is single layer closure sufficient?
simple, nongaping wounds <3cm
What type of suture is recommended for gaping wounds deeper than dermis?
subcuticular buried suture with absorbable suture
When is tissue adhesive/glue contraindicated
complicated wounds
animal bites
mucosal surfaces
across mucocutaneous junction
areas of high tension
What type of wounds require antibiotics?
bite wound
wound with evidence of devascularization
wounds through and through buccal mucosa
involving cartilage of ear or nose
extensive contamination
immunocompromised patient
How to close lip lacs?
absorbable suture
through and through - in layers: intraoral mucosa and working outward
after mucosal layer done, ++ irrigate external wound to remove lingering bacteria
Do small lacs of tongue or oral mucosa need repair?
generally no
Which tongue lacs need repair?
gape
collect food
heal w/ sign divot/scar
Contusion of cheek raise suspicion for which 2 #?
zygomatic
maxillary
Should pt with nasal packing in for epistaxis get prophylactic abx?
per rosens, no
could consider chlorhex-neomycin (naseptin) if wanted to
To best determine nasal bone deformity over bridge, when is acceptable outpt referral?
3-5d
for chldren within 3d and rpt exam 7d as want to ensure appropriate growth
Laceration of underlying cartilage of ear - what suture to use?
absorbable suture
If the cartilage of the pinna has to be repaired, abx coverage prophylactic recommended to cover which bugs?
pseudmonas
Any injury to lacrimal sac/duct should warrant consult to who?
facial specialist
When are facial fracture repairs most easily performed?
within 7d, develop firm fibrous union within 10-14d
Which facial fractures require abx?
open #
those that violate a sinus
Which fractures of the face require caution in sneezing/blowing nose?
nasoethmoid complex violating maxillary bone or floor of orbit
What fracture often requires chatting with a specialist given its cosmetic factor?
frontal skull
If fracture through anterior wall of frontal sinus is seen, what needs to be done?
often continue throughout to posterior, ct
if + then consider CSF leak until proven otherwise
In a blow out fracture, what m may get trapped and why?
inferior rectus trapped due to fragments depressing into maxillary sinus
Recommended tx of a blow ou.fracture with inferior rectus m entrapment, infraorbital nerve compression
from contusion and edema and be self-limited, immediate repair is not necessary, but follow-up evaluation is recommended. Repair typically is performed 1 or 2 weeks after the injury for persistent enophthalmos or diplopia.
Medial wall fracture mc sx
diplopia
exopthalmos
Concerning signs of a retobulbar hematoma
elevate retroorbital pressure causing exopthalmos, compartment syndrome –> decr visual acuity/blindness
Tx of retrobulbar hematoma with visual sx
lateral canthotomy with cantholysis
Trimalar fracture of the midface - what bones are involved?
lateral orbit
zygoma
maxilla
Signs of trimalar #
large contusion over cheek bone
enopthalmos
malocclusion of upper teeth
What do all Le Fort fractures involve?
pterygoid plate
Mandible fracture, given shape, if see one fracture…
check for more!
Which mandible fractures require early splinting by typically wired shut?
symphysis
body
angle
rami
Mandible fractures - impact, nondisplaced treated how? vs coronoid?
soft diet, pain control
coronoid - no intervention (* as decided by specialist)
Tooth fracture classification system
ellis
class I ellis fracture
enamel of tooth only
not painful
can await dental eval
class II ellis fracture
expose yellow dentin
may be painful
can await dental assessment but should be dressed with ca hydroxide and aluminum foil
class III ellis fracture
painful
exposed dental pulp - red line/dot
++ early eval dentist or endodontist
How to perform reimplanatation of a tooth
do not disturb the socket
rinse to tooth (not wiped)
place into socket where clicks
After reimplantation, the tooth requires stabilization with acrylic splint or wiring to the adjacent teeth. Appropriate antibiotics such as penicillin and tetanus immunization prophylaxis should be given, as well as dental follow-up for possible root canal if the reimplantation does not take.
When should a tooth not be removed?
partially avulsed
extruded or laterally luxated
If a tooth is intruded…
do not manipulate it
How to perform a dental block
Area of a single socket may be anesthetized by placing approximately 0.5 mL of 1% lidocaine with epinephrine into the buccal sulcus and gum on the outer side of the alveolar ridge.
How quickly should a tooth be implanted for best results?
20-30min
What is another concern (think airway) of avulsed teeth
aspiration - make sure they don’t choke on tooth
TMJ: In unilateral dislocation, the jaw is rotated laterally __ from the affected joint; bilateral disloca- tion causes significant protrusion of the jaw
away
Denver screening RF for BCVI - name 8
high E trauma
complex skull fracture
severe tbi or gcs <6
thoraic injury
seatbelt injury with abrasion, swelling or pain
scalp degloving
severe facail fracture - lefort II or III
mandible fracture
hanging/clothes line neck injury
tbi with thoracic injury
blunt cardiac rupture
first rib fracture
What dx can ultrasound of eye determine?
lens disloc
vitreous hemorrh
retinal detachment
globe rupture
Key concepts in management of frontal bone injury
atls
consult specalist
Key concepts in management of orbital injury
optho
f/u 1 week
avoid blowing/sneezing with closed mouth
Key concepts in management of nasal injury
tx any septal hematma and epistaxis
consider closed reduction
otolaryngology f/u
Key concepts in management of midface injury
control bleed
surgical consult post imaging
Key concepts in management of mandibular injury
control bleed
if dental involvement, consider as open # and tx with appropr abx
image and appropriate surgical consult
Gunshot wounds to the l? of the face are particularly likely to require intubation for airway protection,
ower third
A patient presents following a physical altercation complaining of eye pain, decreased vision, and swelling. On physical exam- ination he is noted to have periorbital ecchymosis, swelling, and tenderness, an irregular, tear-shaped pupil, and a collection ofblood in the anterior chamber of the eye. Which of the following diagnostic or treatment options should be avoided?
A. CT imaging of the face
B. Ophthalmologic consultation
C. Prophylactic antibiotics
D. Thorough eye examination including tonometry
E. Medications for pain and nausea and place patient in semire-
cumbent position
concerning for globe rupture - d
Cribiform plate fracture assoc with what brain pathology?
csf leak
