Facial Trauma Flashcards
Discuss physical examination of the eyes and orbit
Assess the relative position of the eyes – orbital fractures can cause large retro-orbital haematomas which can lead to compartment syndrome of the orbit + exopthalmus
Anterior chamber should be examined for signs of hyphema or globe rupture.
VA if able
Ph of the eye if chemical involvement suspected
Fluroscene for corneal damage +- seidles for globe rupture.
EOM testing for entrapment
Neuro examination of the face for entrapement of CN V( fracutre through the infraorbital foramina) and 7
Discuss physical examination of the oropharynx
Intra-oral examination nicludes inspection of the palate teeth ntoungue and gumes and palpation with a gloved finger.
ROM of the mandible should be noted - trismus is likley to represent either a mandibular fracture or a significant haematoma
Assess for normalcy of bite
Injury to the parotid region should raise the possibility of injury to stensens duct. The opening of the duct over the second upper molar should be examined for bleeding while the gland is compressed. If blood is present or the severed end of the gland is visible surgical repair is requried to avoid cutanous fistula formation.
Discuss physical examination of the ear
look for haemotymponum – BOS
clear fluid should raise the concern of CSF leak – Halo test – drop of this fluid on a filter paper leads to a rapidly expanding halo around the drop is positive for CSF - 86% sensititve
Discuss laceration to mouth and surrounding areas
Aethetics is the most important consideration in closure of these wounds
Vermillian border should be lined up
Laceration near the parotid (stensens) or submandibular( whartons) should be assessed for duct injury - if possible should be assessed by a facial specialist
Small laceration of the toungue or intraoral mucosa do not need to be reapired- gaping wounds should be well washed out and closed in layers
regardless of closure or not should be advised for gentle cleansing (swish and spit) with a mild antiseptic
Discuss perioral burns (electircal)
Children use there mouths to explore and stick electrical shit there.
The wet oral mucosa provides little resistance and current penetrates to deeper structure
Perioral burns resulting from these injuries can result in significant cosmetic affects. The initial appearance of the wound may be misleadingly trivial with oedema and necrosis progressing over several days. The defect may become disfiguring
Bleeding from the labial artery is a concern when the maturing exchar separates from underlying structures at approximatly 4 weeks post burn.
General current practice is discharge from the ED with close follow-up and ENT + plastic follow up if required,
Possibility of NAI should be suscpected with these
Discuss soft tissue injury to the nose
Epistaxis should be controlled with 10 minutes of compression – if not able to be controlled anterior packing may be needed. concern for development of staph septic shock but nil evidence to suggest prophylaxis reduces this
need to assess for septal haematoma which would need to be drained – simple incision prior to packing, if not done will lead to necrosis
If able to breath through both nostrils, nil septal haematoma and aethetic looks reasonable nil need for further eveluation in the ED. Can be sent to ENT for follow-up. Cna be difficult to assess adequacy of the aethetic affect if significant oedema and would require followup for this 3-5 days later m
If cartilage involved needs to be closed in seperate layer
Children with nasal fracture may have premature closure of the sutures and uneven gorwth particularly of the vomerospetal line. Should be referred for ENT review 3-5 days later
Infraorbital or supratrocheal blocks can be used for anaethetics of the nose
Discuss soft tissue injury to the ear
Blunt trauma to the ear can cause haematoma formation in the subperichondrial potential space. Such haematomas are the preclude to the development of cauliflower ear and should be drained. - reaccumulation of the haematoma is prevented with a compressive dressing of the ear.
Ear laceration often involve the cartilage and should be closed in layers. Becuase chondritis is avascular when condritis occurs it often requires large areas of debridement and can be disfiguring.
If repair of cartilage of the pinna is required prophylactic antibiotics are reccomended – covering typical skin flora and pseudomonas
Discuss soft tissues injury to the eye
Assess for lacrimal involvement may need consult- intesgrity can be assessed by instilling fluroscene dye into the eye
Discuss orbital fractures
The most common orbtial fracture is a blow out fracture of the orbital floor – caused by a fisted blow or ball striking the orbit – often isolated fractures. Care need to be taken to ensure that the inferior rectus is not entrapped which would lead to inability to elevate the globe - diplopia on upwards gaze
The infraorbital nerve can also be compressed leading to anaethesia in the atnterior medial cheek and upper lip. - Signs of above may be due to oedema and not require repair but should be discussed with maxfax
Fractures involving the medial orbital wall are often associated with nasal injury and more generalised midface fracutres. Herniation of the orbital contesnts into the ethmoids is common and these patient more likley present with ocular signs of diplopia or expothalmos.
Fractures of the superior portion of the orbit involve in the base of the frontal sinus – need to be catious in regards to cosmetic affects and intracranial injury
Any injury to the orbit can cause a haematoma to form within the orbit leading to exopthalmos and compartment syndrome, rarely subcutaneous emphysema can have the same effect – these are true emergency and require a lateral canthotomy with cantholysis to save the patient vision
Discuss canthotomy and cantholysis
Appropriate anaethesia
Use needle driver or haemostat to crush the tissue from the lateral canthus to the rim of the orbit for 20 sec to 2 min- help minimise bleeding
Use iris scissors to cut from the latearl canthus to the rim of the orbit (canthotomy)
Cut the inferior and sometimes both crus of the lateral canthal ligament
Next re-assess if pressure not relieved cut the superior crus
Dicsuss signs suspicious for orbital compartment syndrome
Clinical signs suspicious for decreased perfusion from orbital compartment syndrome include:
decreased visual acuity,
intraocular pressure higher than 35-40mmHg,
a relative afferent pupillary defect or
decreased arterial circulation of the optic nerve visualized by the absence of flow or pulsing of retinal arteries with minimal or no digital pressure on the globe.
Discuss midface fractures
Lefort system is the most commonly used
All lefort grades include the pterygoid plate
Lefort 1 - involves a transverse fracture through the maxilla above the roots of the teeth - may be unilateral or bilateral. Patients often report malocclusion of the teeth and the the maxilla may be mobile when the upper teeth are grasped
Lefort 2 - typically bilateral and pyramidal in shape. Extends superiorly in the midface to include fractures of the nasal bridge, maxilla, lacrimal bones, orbital floor and rim. The nasal complex moves as a unit with rocking of the superiour teeth.
Lefort 3- seperation of the elements of the skull and face. Start at the bridge of the nose, extend posteriorly along the medial wall of the orbit (ethmoid) along the floor of the orbit (maxilla) and through the lateral orbital wall and finally break through the zygomatic arch. They are freuently associated with CSF leaks
Prohpylxasis for CSF is controversial – all immunocomprised peeps for sure
Anterior nasal packing is safe in patient with multitrauma who a skeletally mature.
Discuss fractures of the zygoma
relatively rare and a result of direct trauma – Becuase the condyle of the mandible may disturb zygomatic gragments while moving these patient often present with trismus and require surgical repair.
Discuss mandibular fractures
Due to the shape of mandible multiple fractures can occur secondary to a single impact.
Depending on the site of the fracture the patient may have trismus (fracture of the coronoid process, neck or rami), dental malocculsion, swellign and tenderness intraorally or externally
Fractures of the symphysis, body angle or rami usually require early splinting. Most will require hospitisation. If open need ABs
Isolated coronoid fractures require nil intervention
Discuss Ellis system of tooth fractures
Class1 - involves enamel of the tooth only and ar not painful – dental OPD
Class 2 - expose the yellow dentin and may be painful - dress with calcium hydroxide and aluminum foil - dental OPD
Class 3 - expose the dental pulp, seen as a red dot or line - exquistely painful – require early evaulation by dentist or endodontist
Discuss management of tooth avulsion
Gentle rinse of the root do not wipe - place into to the socket where a click should be felt - paritally evulsed, extruded or altearlly luxated teeth should not be remoed but relocated – likley will need regional block or local anaethetic
- reimplanted teeth may or may not take acutely and can take up0 to weeks to assess the final success or failure of re-implantation
Teeth that are re-implanted within 30 minutes have fewer complications – younger age does better
In children esepcially the frontal maxillary incisors if re-implanted may ankylose and fail to grow requiring further treatment – most common age for this complications is 6-10 years of age
CXR for aspirated avulsed teeth
Discuss TMJ trauma
Trauma to the TMJ may tear the meniscus or injure the collateral ligaments holding it in normal position. This can lead to inability to open the mouth or painful clicking. Patient without fracture but painful mouth opening should be asked not to yawn or attempt forceful opening and be referred to Max fax
Discuss TMJ dislocation
Most commonly occurs with wide yawning laughing, kissing or singing. Can be unilateral or bilateral. In unilateral dislocation the jaw is rotated laterally away from the affected joint. Patient present with mouth so far open that they have difficulty with managing there secretion and can be actively drooling.
Trauma with enough force to dislocate the TMJ usually causes a co-current fracture
Occurs when the mandibular condyle travels anteriorly along the articular eminence and becomes locked in the anterior superior aspect of the eminence preventing closure of the mouth – dislocation results in stretching of the ligaments and is associated with severe spasm of the msucles that open and close the mouth
Discuss TMJ dislocation reduction techniques and discharged advise
Syringe method – 5 or 10 ml syringe is placed between the posterior upper and lower molars or gums on one of the affected sides - size is chosen to fit easily between the molars – patient is advised to bit down on the syringe and roll it back and fowards until reduction is acheived – typically the oposite will spont resolve if also dislocated if not place the syringe on the contralateral side
Manual reduction
Patient seated upright- adequate analgesia and sedation are required for success. Place the thumb or index finger into the buccal sulcus on either side of the mouth the angle of the jaw is pressed downward to free the condyles from the anterior aspect of the eminence while the symphysis is rotated (chin) upwards and backward.
Discharge advise
- Avoid extreme opening of the jaw for three weeks
- support jaw when yawning
- apply warm compress to the TMJ for 24 horus
- maintain a soft diet for one week
- Take NSaids and paracetmaol as needed
- Maxfax review
Discuss imaging of facial fractures
OPG or CT
Any one with horners, lefort 2 or 3, BOS or neck soft tissue injury should have a CTA
Ultrasound can be used to assess ocular trauma if it is suspected – can easily identify lens dislocation, vitreous haemorrhage, retinal detachement and globe rupture. 94% correlation with axial coronal CT imaging
Discuss management of facial injuries
ABCD
Unless exsanguinaton or airway is a concern most facial injuries can be deferred until more life threatening injuires have been stabilized.
Out of hosptial
- special attention to facial haematoma – these can expand rapidily and extend into the neck or down the supraclavicular area - such haematomas greatly distort the normal anatomy of the pharynx and the trachea and can make both intubation and front of neck assess difficult
- need to consider possibility of awake oral intubation or front of neck assess in the field
- If significant intraoral bleeding patient may need to be itubated to facilitate oral packing to stop bleeding.
- If globe rupture susepceted protect against compression of the eye ( eg. eye cup, non contact shielding)
- Avulsed parts should be transpoted with the patient in saline soaked gauze
- if awake can carry avulsed teeth in buccal fold
In ED
- readress airway – consider fibreoptic awake intubation if difficulty is likley to arise
- be aware if significant distortion LMA may not provide adequate seal to ventilate
- TXA if massive bleeding
