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Facial trauma Flashcards

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1
Q

How does facial trauma appear according to age?

A

Tri-phasic
1st peak in children
2nd peak in 20s
3rd peak in elderly

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2
Q

What is facial trauma related to? (3)

A

Road traffic accidents
Falls
Assault

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3
Q

How is facial trauma related to SES?

A

Higher incidence in lower SES

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4
Q

How is facial trauma related to gender?

A

Higher incidence in males
Males more risk taking behaviours

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5
Q

What laws are in place to reduce severity of facial trauma from road traffic accidents?

A

Seatbelt laws for driver and all passengers
Air bags installed in cars

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6
Q

What are the mechanisms of facial trauma incidents? (4)

A

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

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7
Q

With any trauma pt what should you immediately consider?

A

ABC
Airway
Breathing
Circulation

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8
Q

What other injuries are associated with facial trauma?
(Order of most to least common)

A

Brain (45%)
Chest
Abdomen/pelvis
Spinal
Long bones

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9
Q

Define a fracture

A

Break in the continuity of a bone

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10
Q

Define displacement of fracture

A

Extent 2 sides of a fracture have moved from their normal position

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11
Q

Define angulation of fracture

A

Angle which one fragment has moved compared to its previous position

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12
Q

Define compound fracture
What is it AKA?

A

Fracture open to external environment by a tear/laceration to overlying soft tissues
AKA Open fracture

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13
Q

Where are compound fractures seen orally?

A

In mandible

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14
Q

Define comminuted fracture

A

Complex fracture with more than 2 bone fragments at fracture site

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15
Q

Define pathological fracture

A

Fracture in an area of bone that has been critically weakened by disease e.g. cancer / osteoradionecrosis / MRONJ / large cyst

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16
Q

What forces are facial bones designed to withstand?
And not?

A

Masticatory forces - up and down
Not forces from the front / side

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17
Q

What is atrophic mandible?

A

Thin mandible

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18
Q

How does atrophic mandible occur?

A

Naturally with age - mandibular ridge resorption

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19
Q

What is the risk with atrophic edentulous mandible?

A

Bilateral fracture with displacement

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20
Q

What causes the displacement of fractures in an atrophic edentulous mandible?

A

MoM
- Masseter
- Temporalis
- Lateral pterygoid

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21
Q

Anatomically what may be the risk associated with a fracture in the zygomatic arch?

A

Fracture may be displaced and impinge into the temporalis MoM causing trismus

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22
Q

What should you consider anatomically in a mandibular fracture?

A

IAN damage - may cause lip numbness

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23
Q

What should you consider anatomically in a fracture of the floor of the orbit?

A

Infraorbital nerve
Superior alveolar nerve

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24
Q

Which mandibular fractures are easiest and hardest to access?

A

Compound = easier
Closed = harder

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25
Q

Where do the majority of mandibular fractures occur?

A

Condyle
OR
At angle of mandible
OR
Body of the mandible

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26
Q

What are considered closed fractures of the mandible?

A

Condyle
Ramus
Coronoid process

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27
Q

Why are mandible fractures bilateral?

A

Mandible is a curved bone with limited mobility at each end

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28
Q

What is considered a Guardsman fracture?

A

(Falling flat on chin)
Midline fracture
Fracture at each condyle from impact

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29
Q

Anatomically what is the zygoma attached to?

A

Orbital floor
Maxillary wall
Zygomatic arch

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30
Q

Impacts of zygoma fracture?

A

Changes in vision
Flattening of cheek prominence
Damage to infraorbital nerve

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31
Q

How are fractures of the mid face classified?

A

By Le Fort
3 types

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32
Q

What is Le Fort 1?

A

Fracture of apices of maxillary teeth

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33
Q

What is Le Fort 2?

A

Fracture between maxilla and nose

34
Q

What is Le Fort 3?

A

Fracture in region of maxilla, zygoma and orbital floor

35
Q

How should facial trauma be examined?

A

EO
IO
Radiograph

36
Q

What should EO exam consist of regarding facial trauma?

A

Visual inspection
Palpation

37
Q

What is a black eye technically known as?

A

Circumorbital ecchymosis (bruising)

38
Q

What is a blood shot eye technically known as?

A

Subconjunctival haematoma

39
Q

How is subconjunctival haematoma acquired?

A
  • Direct trauma
  • Bony fracture to wall of orbit
40
Q

What should be included in visual inspection?

A

Bleeding and its source
- Nose
- Mouth
- Lacerations to skin

Bruising
Swellings
Flattening
Check eye movements
Check for double vision

41
Q

Why should you palpate facial swellings?

A

Assess for surgical emphysema - should feel like bubble wrap

42
Q

If surgical emphysema identified following palpation, what else should be considered regarding facial trauma?

A

Maxillary sinus

43
Q

What should be included in palpation?

A

Check skin sensation with light touch, compare RHS with LHS
CN5 - Trigeminal
- Opthalamic branch
- Maxillary branch
- Mandibular branch

44
Q

What should IO exam include?

A
  • Count the teeth
  • Check gingivae for tears / bruising / bleeding / steps
  • Check for malocclusion
45
Q

Why is it crucial to count teeth in facial trauma?

A

Gaps in occlusion are not always missing teeth

46
Q

What should radiographic exam include?

A

2 radiographs diff angles

47
Q

Why are 2 radiographs at diff angles needed?

A

May miss fractures with 1
Assess displacement
Assess angulation

48
Q

Which specific radiographs can be used to examine mandible?

A

OPT
Mandibular PA

49
Q

What radiographic views are required to examine mid face or zygoma?

A

Occipitomental view
Specialist views: Submental vortex, Towne’s

50
Q

What can an occipitomental view show?

A

Fluid level
Infraorbital margin
Zygomatic buttress
Zygomatic arch

51
Q

Advantages of a CT scan for mid face radiograph?

A

Detail
Gives info about angulation and displacement of fracture

52
Q

Stages of wound healing (4)

A

Haemostasis
Inflammatory
Proliferative
Remodelling

53
Q

Time period for haemostasis

A

Seconds to hours

54
Q

What happens in haemostasis

A

Vasoconstriction
Platelet aggregation
Leukocyte migration
Clot formation
Fibrin meshwork forms

55
Q

Time period for inflammatory phase

A

Hours to days

56
Q

What happens in inflammatory phase?

A

Early - cellular phase
- Activation of serum complement
- Neutrophils activated

Late - vascular phase
- Vasoconstriction of disrupted vessels
- Coagulation promoted

Phagocytosis and removal of foreign bodies

57
Q

Time period of proliferative phase

A

Days to weeks

58
Q

What happens in proliferative phase?

A

Fibroblast proliferation
Collagen synthesis
ECM reorganisation
Angiogenesis (making new BVs)
Granulation tissue formed

59
Q

Time period for remodelling phase

A

Months

60
Q

What happens in remodelling phase?

A

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

61
Q

Requirements of bone healing?

A

Needs to heal at right angulation in right position, to right length

62
Q

Impacts of incorrect bone healing

A

Disability to some extent

63
Q

How long should bone be held in position? Why?

A

6 weeks
Hard callus to form
Sufficient strength without splint

64
Q

When splinting bones what should we prevent and encourage?

A

Prevent - movement
Encourage - physiological stress

65
Q

What is the most important thing to consider with mandibular / maxillary fracture?

A

Occlusion

66
Q

How are mandibular / maxillary fractures held in place?

A

Correct the occlusion then surgically place a titanium plate

67
Q

What are risks involved with a fracture plate?

A

Surgical procedure
Scar
Nerve damage
GA complications related to medx

68
Q

Compare plaster cast to fracture plate

A

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

69
Q

What are the 4 principles of fracture management?

A

Speed vs safety
Stability vs mobility

70
Q

What is the challenge with atrophic mandibles / edentulous mandibles?

A

Muscles pull in awkward directions
- Masseter and temporalis pull up at the back
- Mylohyoid pulls down at the front

71
Q

What can happen with pts who have had zygoma or orbital fractures?

A

Retrobulbar haematoma - can lead to loss of vision in this eye

72
Q

How would you manage pt following zygoma or orbital fracture?

A

Monitor vision / acuity etc for 24-48 hours after operation

73
Q

What should we consider for pts post surgery of facial fractures?

A

Nutrition and fluids

74
Q

What may occur with a pt with inter maxillary fixation?

A

Acts as a PRF which can lead to poor OH, caries, periodontal disease etc.

75
Q

What should we advise pts against in 6 weeks following facial fracture surgery?

A

Avoid sugary foods and drinks to get daily calorie intake - eat healthy foods

76
Q

What are some direct consequences of facial fractures?

A

Cosmetic problems - scarring
Eyesight problems - retrobulbar haematoma
Nerve damage
Infection

77
Q

What are some consequences of facial fracture healing? (3)

A

Malunion
Delayed union
Non union

78
Q

What is a malunion?

A

Fracture heals but not at correct length / angulation
Can lead to cosmetic deformity, altered muscle function

79
Q

What is delayed union?

A

When bone hasn’t healed after 6 weeks

80
Q

What are risks with delayed union?

A

Plate fracturing
Screws can pull out through the bone / become loose

81
Q

What is non union? What can it lead to?

A

Bone fragments heal but do not unite
Can lead to pseudo arthrosis

82
Q

What are the tx options for facial fracture?

A
  • 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

CMS (10 decks)

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