Facial trauma

Question 1

What is a compound fracture?

Answer 1

A fracture open to external environment through a tear/laceration in overlying skin/mucosa. (most mandible fractures)

Question 2

What is a comminuted (complex) fracture?

Answer 2

A complex fracture pattern with more than two bone fragments at the fracture site. (usually a high impact/energy fracture)

Question 3

What is a pathological fracture?

Answer 3

Fracture in an area of bone that has been critically weakened by disease (cancer, osteoradionecrosis, MRONJ, cysts)

Question 4

Why are elderly people more at risk of breaking their mandible/maxilla?

Answer 4

Mandibular ride resorption with lost teeth and age

Question 5

What is a bucket handle fracture?

Answer 5

Bilateral edentulous mandible fracture

Question 6

What can a fracture of the orbital floor cause?

Answer 6

Herniated trapped medial rectus muscle causing diplopia (double vision)

Question 7

What intraoral nerves can be affected by facial fractures?

Answer 7

Inferior alveolar
Superior alveolar

Question 8

What does a floor of orbit fracture usually present with?

Answer 8

Numbness of cheek, side of nose and upper lip

Question 9

What is a retrobulbar haematoma?

Answer 9

Pressure stops venous drainage behind the eyeball, causes congestion in retina that causes pain and can cause permanent blindness.

Question 10

What is a guardsman fracture?

Answer 10

Results in mid line and bilateral condyle fracture which is common in people that fall flat on their face.

Question 11

What are the 3 fracture patterns of the face?

Answer 11

Le fort 1 - above apices
Le fort 2 - maxilla and nose
Le fort 3 - maxilla, zygomas and orbital floor

Question 12

What don’t zygomatic arch fractures involve?

Answer 12

The occlusion

Question 13

What can you physically inspect in a patient who has had a facial injury?

Answer 13

• inspection
• palpation
• percussion
• auscultation

Question 14

If there is a facial swelling why should you palpate it?

Answer 14

If the swelling feels like bubble wrap it may suggest surgical emphysema (air in tissues)

Question 15

Why do you sometimes examine a patient from a bird’s eye view?

Answer 15

Can see flattening of the body of zygoma easier

Question 16

What should you examine in a patient who has had facial trauma?

Answer 16

ABC!
Loss of consciousness?
Check for bruising, subconjunctival haematoma,
Bleeding - nose mouth lacerations
Swelling
Flattening
Eye movements - check for upwards motion, and double vision
Palpation - check skin sensation of trigeminal

IO: gingival step/tear
Count the teeth
Malocclusion?

Question 17

What malocclusion do you normally get with bilateral condyle fractures?

Answer 17

Anterior open bite

Question 18

What radiographic examination should be taken to assess displacement and angulation of fractures?

Answer 18

OPT and PA of mandible - good for angle and condyle fractures

Question 19

What other radiographic techniques can be used for facial fractures IF you don’t have a CT?

Answer 19

• Reverse Townes
• Mid face

Question 20

What radiographic view can you do to look at the zygomatic arch?

Answer 20

Submentovertex view - from underneath the chin to the top of the skull

Question 21

What is the best scan to do for a facial fracture?

Answer 21

CT - gives information and detail about angulation and displacement of fracture

Question 22

What are the 4 stages of fracture healing?

Answer 22

1) Inflammatory - haemorrhage in the area
2) Proliferative - fibroblasts proliferate, macrophages devour debris and fibrous tissue layed down to stabilise fracture (soft callus)
3) Bony callus - differentiation of osteoblasts and osteoclasts to produce bone matrix
4) Remodelling - bony callus is reduced in size and bone ends are remodelled to become whole bone

Question 23

What are the requirements for bone healing?

Answer 23

• reduce fracture
• restore length of bone
• restore angulation

Question 24

What does a fracture need to heal?

Answer 24

Holding in position (around 6 weeks) with a little bit of movement and stress to help the healing.
Joints have to be the right distance apart and angulation, if the fracture doesn’t heal in the right angulation or length the joint will not work properly.

Question 25

What are the priorities when treating facial fractures?

Answer 25

• restore function
• zygoma fractures - eyesight
• restore appearance

Question 26

What are the principles of fracture management?

Answer 26

• Speed, safety, mobility and stability

Question 27

What are the options for management of fractures?

Answer 27

• Conservative management
• MUA (manipulation under anaesthesia)
• IMF (intermaxillary fixation)
• ORIF (open reduction internal fixation) - plating

Question 28

Why are atrophic mandibles at risk of ORIF?

Answer 28

Muscles pull in an awkward positions, reconstructive plates are used to counteract forces of muscles

Question 29

What is another option for splinting for fractured edentulous mandibles?

Answer 29

Gunning splint

Question 30

What do you have to monitor post operatively after management of fractures?

Answer 30

Eye observations for zygoma/orbital fractures - risk of retrobulbar haematoma
Nutrition

Question 31

What are complications of fracture management?

Answer 31

• Nerve damage
• Eyesight (muscle entrapment, retrobulbar haematoma)
• Malunion
• Malocclusions
• Delayed union (risk of plate fracture)
• Non -union (can develop pseudojoint)