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Facial trauma Flashcards

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
Where do the majority of mandibular fractures occur?
Condyle OR At angle of mandible OR Body of the mandible
26
What are considered closed fractures of the mandible?
Condyle Ramus Coronoid process
27
Why are mandible fractures bilateral?
Mandible is a curved bone with limited mobility at each end
28
What is considered a Guardsman fracture?
(Falling flat on chin) Midline fracture Fracture at each condyle from impact
29
Anatomically what is the zygoma attached to?
Orbital floor Maxillary wall Zygomatic arch
30
Impacts of zygoma fracture?
Changes in vision Flattening of cheek prominence Damage to infraorbital nerve
31
How are fractures of the mid face classified?
By Le Fort 3 types
32
What is Le Fort 1?
Fracture of apices of maxillary teeth
33
What is Le Fort 2?
Fracture between maxilla and nose
34
What is Le Fort 3?
Fracture in region of maxilla, zygoma and orbital floor
35
How should facial trauma be examined?
EO IO Radiograph
36
What should EO exam consist of regarding facial trauma?
Visual inspection Palpation
37
What is a black eye technically known as?
Circumorbital ecchymosis (bruising)
38
What is a blood shot eye technically known as?
Subconjunctival haematoma
39
How is subconjunctival haematoma acquired?
- Direct trauma - Bony fracture to wall of orbit
40
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
41
Why should you palpate facial swellings?
Assess for surgical emphysema - should feel like bubble wrap
42
If surgical emphysema identified following palpation, what else should be considered regarding facial trauma?
Maxillary sinus
43
What should be included in palpation?
Check skin sensation with light touch, compare RHS with LHS CN5 - Trigeminal - Opthalamic branch - Maxillary branch - Mandibular branch
44
What should IO exam include?
- Count the teeth - Check gingivae for tears / bruising / bleeding / steps - Check for malocclusion
45
Why is it crucial to count teeth in facial trauma?
Gaps in occlusion are not always missing teeth
46
What should radiographic exam include?
2 radiographs diff angles
47
Why are 2 radiographs at diff angles needed?
May miss fractures with 1 Assess displacement Assess angulation
48
Which specific radiographs can be used to examine mandible?
OPT Mandibular PA
49
What radiographic views are required to examine mid face or zygoma?
Occipitomental view Specialist views: Submental vortex, Towne's
50
What can an occipitomental view show?
Fluid level Infraorbital margin Zygomatic buttress Zygomatic arch
51
Advantages of a CT scan for mid face radiograph?
Detail Gives info about angulation and displacement of fracture
52
Stages of wound healing (4)
Haemostasis Inflammatory Proliferative Remodelling
53
Time period for haemostasis
Seconds to hours
54
What happens in haemostasis
Vasoconstriction Platelet aggregation Leukocyte migration Clot formation Fibrin meshwork forms
55
Time period for inflammatory phase
Hours to days
56
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
57
Time period of proliferative phase
Days to weeks
58
What happens in proliferative phase?
Fibroblast proliferation Collagen synthesis ECM reorganisation Angiogenesis (making new BVs) Granulation tissue formed
59
Time period for remodelling phase
Months
60
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
61
Requirements of bone healing?
Needs to heal at right angulation in right position, to right length
62
Impacts of incorrect bone healing
Disability to some extent
63
How long should bone be held in position? Why?
6 weeks Hard callus to form Sufficient strength without splint
64
When splinting bones what should we prevent and encourage?
Prevent - movement Encourage - physiological stress
65
What is the most important thing to consider with mandibular / maxillary fracture?
Occlusion
66
How are mandibular / maxillary fractures held in place?
Correct the occlusion then surgically place a titanium plate
67
What are risks involved with a fracture plate?
Surgical procedure Scar Nerve damage GA complications related to medx
68
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
69
What are the 4 principles of fracture management?
Speed vs safety Stability vs mobility
70
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
71
What can happen with pts who have had zygoma or orbital fractures?
Retrobulbar haematoma - can lead to loss of vision in this eye
72
How would you manage pt following zygoma or orbital fracture?
Monitor vision / acuity etc for 24-48 hours after operation
73
What should we consider for pts post surgery of facial fractures?
Nutrition and fluids
74
What may occur with a pt with inter maxillary fixation?
Acts as a PRF which can lead to poor OH, caries, periodontal disease etc.
75
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
76
What are some direct consequences of facial fractures?
Cosmetic problems - scarring Eyesight problems - retrobulbar haematoma Nerve damage Infection
77
What are some consequences of facial fracture healing? (3)
Malunion Delayed union Non union
78
What is a malunion?
Fracture heals but not at correct length / angulation Can lead to cosmetic deformity, altered muscle function
79
What is delayed union?
When bone hasn't healed after 6 weeks
80
What are risks with delayed union?
Plate fracturing Screws can pull out through the bone / become loose
81
What is non union? What can it lead to?
Bone fragments heal but do not unite Can lead to pseudo arthrosis
82
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

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