Facial trauma Flashcards
How does facial trauma appear according to age?
Tri-phasic
1st peak in children
2nd peak in 20s
3rd peak in elderly
What is facial trauma related to? (3)
Road traffic accidents
Falls
Assault
How is facial trauma related to SES?
Higher incidence in lower SES
How is facial trauma related to gender?
Higher incidence in males
Males more risk taking behaviours
What laws are in place to reduce severity of facial trauma from road traffic accidents?
Seatbelt laws for driver and all passengers
Air bags installed in cars
What are the mechanisms of facial trauma incidents? (4)
High energy transfer
E.g. hitting face in windscreen when not wearing seatbelt
E.g. pedestrian / motorcyclist hit by a car
High energy penetration
E.g. gun shot wound
Low energy transfer
E.g. fall
E.g. assault with a fist
E.g. person on person collision in sports
Low energy penetration
E.g. stab wound
With any trauma pt what should you immediately consider?
ABC
Airway
Breathing
Circulation
What other injuries are associated with facial trauma?
(Order of most to least common)
Brain (45%)
Chest
Abdomen/pelvis
Spinal
Long bones
Define a fracture
Break in the continuity of a bone
Define displacement of fracture
Extent 2 sides of a fracture have moved from their normal position
Define angulation of fracture
Angle which one fragment has moved compared to its previous position
Define compound fracture
What is it AKA?
Fracture open to external environment by a tear/laceration to overlying soft tissues
AKA Open fracture
Where are compound fractures seen orally?
In mandible
Define comminuted fracture
Complex fracture with more than 2 bone fragments at fracture site
Define pathological fracture
Fracture in an area of bone that has been critically weakened by disease e.g. cancer / osteoradionecrosis / MRONJ / large cyst
What forces are facial bones designed to withstand?
And not?
Masticatory forces - up and down
Not forces from the front / side
What is atrophic mandible?
Thin mandible
How does atrophic mandible occur?
Naturally with age - mandibular ridge resorption
What is the risk with atrophic edentulous mandible?
Bilateral fracture with displacement
What causes the displacement of fractures in an atrophic edentulous mandible?
MoM
- Masseter
- Temporalis
- Lateral pterygoid
Anatomically what may be the risk associated with a fracture in the zygomatic arch?
Fracture may be displaced and impinge into the temporalis MoM causing trismus
What should you consider anatomically in a mandibular fracture?
IAN damage - may cause lip numbness
What should you consider anatomically in a fracture of the floor of the orbit?
Infraorbital nerve
Superior alveolar nerve
Which mandibular fractures are easiest and hardest to access?
Compound = easier
Closed = harder
Where do the majority of mandibular fractures occur?
Condyle
OR
At angle of mandible
OR
Body of the mandible
What are considered closed fractures of the mandible?
Condyle
Ramus
Coronoid process
Why are mandible fractures bilateral?
Mandible is a curved bone with limited mobility at each end
What is considered a Guardsman fracture?
(Falling flat on chin)
Midline fracture
Fracture at each condyle from impact
Anatomically what is the zygoma attached to?
Orbital floor
Maxillary wall
Zygomatic arch
Impacts of zygoma fracture?
Changes in vision
Flattening of cheek prominence
Damage to infraorbital nerve
How are fractures of the mid face classified?
By Le Fort
3 types
What is Le Fort 1?
Fracture of apices of maxillary teeth
What is Le Fort 2?
Fracture between maxilla and nose
What is Le Fort 3?
Fracture in region of maxilla, zygoma and orbital floor
How should facial trauma be examined?
EO
IO
Radiograph
What should EO exam consist of regarding facial trauma?
Visual inspection
Palpation
What is a black eye technically known as?
Circumorbital ecchymosis (bruising)
What is a blood shot eye technically known as?
Subconjunctival haematoma
How is subconjunctival haematoma acquired?
- Direct trauma
- Bony fracture to wall of orbit
What should be included in visual inspection?
Bleeding and its source
- Nose
- Mouth
- Lacerations to skin
Bruising
Swellings
Flattening
Check eye movements
Check for double vision
Why should you palpate facial swellings?
Assess for surgical emphysema - should feel like bubble wrap
If surgical emphysema identified following palpation, what else should be considered regarding facial trauma?
Maxillary sinus
What should be included in palpation?
Check skin sensation with light touch, compare RHS with LHS
CN5 - Trigeminal
- Opthalamic branch
- Maxillary branch
- Mandibular branch
What should IO exam include?
- Count the teeth
- Check gingivae for tears / bruising / bleeding / steps
- Check for malocclusion
Why is it crucial to count teeth in facial trauma?
Gaps in occlusion are not always missing teeth
What should radiographic exam include?
2 radiographs diff angles
Why are 2 radiographs at diff angles needed?
May miss fractures with 1
Assess displacement
Assess angulation
Which specific radiographs can be used to examine mandible?
OPT
Mandibular PA
What radiographic views are required to examine mid face or zygoma?
Occipitomental view
Specialist views: Submental vortex, Towne’s
What can an occipitomental view show?
Fluid level
Infraorbital margin
Zygomatic buttress
Zygomatic arch
Advantages of a CT scan for mid face radiograph?
Detail
Gives info about angulation and displacement of fracture
Stages of wound healing (4)
Haemostasis
Inflammatory
Proliferative
Remodelling
Time period for haemostasis
Seconds to hours
What happens in haemostasis
Vasoconstriction
Platelet aggregation
Leukocyte migration
Clot formation
Fibrin meshwork forms
Time period for inflammatory phase
Hours to days
What happens in inflammatory phase?
Early - cellular phase
- Activation of serum complement
- Neutrophils activated
Late - vascular phase
- Vasoconstriction of disrupted vessels
- Coagulation promoted
Phagocytosis and removal of foreign bodies
Time period of proliferative phase
Days to weeks
What happens in proliferative phase?
Fibroblast proliferation
Collagen synthesis
ECM reorganisation
Angiogenesis (making new BVs)
Granulation tissue formed
Time period for remodelling phase
Months
What happens in remodelling phase?
Fibroblasts differentiate into osteoblasts and osteoclasts
Osteoclasts lay down bone matrix
Epithelialisation
ECM remodelling
Prev collagen destroyed and replaced by new collagen
Bone marrow occupies socket replacing woven bone
Requirements of bone healing?
Needs to heal at right angulation in right position, to right length
Impacts of incorrect bone healing
Disability to some extent
How long should bone be held in position? Why?
6 weeks
Hard callus to form
Sufficient strength without splint
When splinting bones what should we prevent and encourage?
Prevent - movement
Encourage - physiological stress
What is the most important thing to consider with mandibular / maxillary fracture?
Occlusion
How are mandibular / maxillary fractures held in place?
Correct the occlusion then surgically place a titanium plate
What are risks involved with a fracture plate?
Surgical procedure
Scar
Nerve damage
GA complications related to medx
Compare plaster cast to fracture plate
Plate is faster but more risks involved
Plate is more stable but reduced physiological stress / mobility
Cast is slower but less risks involved
Cast is less stable more more physiological stress / mobility can be applied to fracture
What are the 4 principles of fracture management?
Speed vs safety
Stability vs mobility
What is the challenge with atrophic mandibles / edentulous mandibles?
Muscles pull in awkward directions
- Masseter and temporalis pull up at the back
- Mylohyoid pulls down at the front
What can happen with pts who have had zygoma or orbital fractures?
Retrobulbar haematoma - can lead to loss of vision in this eye
How would you manage pt following zygoma or orbital fracture?
Monitor vision / acuity etc for 24-48 hours after operation
What should we consider for pts post surgery of facial fractures?
Nutrition and fluids
What may occur with a pt with inter maxillary fixation?
Acts as a PRF which can lead to poor OH, caries, periodontal disease etc.
What should we advise pts against in 6 weeks following facial fracture surgery?
Avoid sugary foods and drinks to get daily calorie intake - eat healthy foods
What are some direct consequences of facial fractures?
Cosmetic problems - scarring
Eyesight problems - retrobulbar haematoma
Nerve damage
Infection
What are some consequences of facial fracture healing? (3)
Malunion
Delayed union
Non union
What is a malunion?
Fracture heals but not at correct length / angulation
Can lead to cosmetic deformity, altered muscle function
What is delayed union?
When bone hasn’t healed after 6 weeks
What are risks with delayed union?
Plate fracturing
Screws can pull out through the bone / become loose
What is non union? What can it lead to?
Bone fragments heal but do not unite
Can lead to pseudo arthrosis
What are the tx options for facial fracture?
- Conservative - easiest but not always appropriate
- Immobilise and splint - with inter maxillary fixation or gunning splint - safe non surgical but not fast, limited stability but good mobililty
- Plating - not as safe, but faster, limited mobility but more stability
