Facial Trauma II Flashcards
Stages of bone healing?
Day 1 - Haematoma forms, phagocyte cleans fracture
Fibrocartilage callus formation
Bony callus formation as osteoblasts move to the site
Remodelling of healed bone at 3rd month - lumpy callus of bone before remodelling
Problems with bone healing?
Maluniun = Bone heals in the wrong place
Nonunion = it doesn’t heal
- Non-union can be hypertrophic, oligotrophic, atrophic, necrotic, defect
What does someone with a fractured mandible look like?
Site of injuries:
- Mandible
- Midface
- Orbitozygomatic
- Frontal
- Cranial
Broken Mandible, pt looks:
Gormless - mouth open as hurts to close
Swelling
Bruising
AOB (bony anterior open bite as jaw has been pulled back my the muscle pull so teeth do not meet in the correct place)
Step deformity of mandible - bone separated, common at lower border of mandible
Paraesthesia - angle or parasymphysis common areas to result in paraesthesia
Pain, especially on movement - difficulty eating and speaking
Deranged occlusion
Mucosal tears/bruising
Lost/displaced or fractured teeth
Mobile fragments
Haematoma
Where can fractures of the mandible be?
Condylar process and head Coronoid Angle and ramus Body - anterior, midbody, posterior Symphyseal and parasympyseal (under lower anteriors) May have a butterfly fragment
Types of mandibular fractures?
Simple - 1 piece on 1 side, 1 piece on the other side. Bone snapped like a twig.
Comminuted - smashed to bits (3+ bit break)
Compound - Bone end is sticking through to air = higher risk of bone infection
- Difficult for md fractures to not be compound
- But good blood supply which helps reduce risk of infection
Displaced or non-displaced
Management of mandibular fractures?
Reduction = put it back where it came from (physical movement of 2 broken bits back together)
- Closed by not making a cut in them or open - cut to reach the broken bits
Fixation (metal)
- Load sharing fixation - bulk of force still goes through the bone
vs load bearing fixation takes all of the force from one ends, bypasses the fracture and puts it at the other end. Usually larger plates.
- Rigid fixation = metal transmits force vs flexible = bendy - allows bone to take some weight
- Mini-plates
Intermaxillary fixation (IMF) = arch bars (metal bars) that go around the teeth and wire the jaw together
Midface breaks presentation and causes?
Le fort 1 - if you hit them in the middle of the face, the maxilla breaks
Le fort 2 - break through eye socket
le fort 3 - across nose, across zygoma and down the zygomatic arches
Requires blunt force usually in excess of a punch or baseball bat/headbut
Look gormless
May have palpable step deformity - can feel around the infraorbital rim sometimes
Intraorbital nerve paraesthesia in Le Fort II fracture
AOB Deranged occlusion Sulcus haematoma Odd percussion note when percuss teeth due to whole jaw moving Gross bruising of the palate Midline palatal split
Presentation of a fractured zygoma?
Periorbital haematoma
Facial flattening (after swelling gone down - depression of the malar/flattening of the cheek) so bring them back after swelling reduced to reassess
Palpable infra-orbital/fronto-zygomatic step
Infra-orbital paraesthesia
Trismus as arch goes inwards so no space for your coronoid to move
May get coronoid fractures alongside zygoma fractures
Eye injury at same time common:
- Subconjunctival haemorrhage (red eye)
- Pupillary level
- Enophthalmos - eye sinks further back into head as the orbit has changed shape
- Diplopia as eyeball has moved so brain cannot line up the images
- Limited eye movement
Imaging:
- Occipito mental - view shows the orbital margins, malar buttress and the antrum (can be taken at 10 degrees or 30 degrees)
- Submento vertex: shows zygomatic arch and supra orbital margin
- CT - 3D, can show orbital blow outs
- if unable to account for teeth - consider chest x-ray especially if pt has respiratory symptoms
Ideally 2 views taken to minimise risk of missing fracture
Nasoethmoidal fracture presentation?
Nasal deformity
Traumatic telecanthus
Disrupted medial canthus
Bilateral panda eyes = skull base fracture
Epistaxis
Epiphora = runny eyes
CSF leak - CSF can come through nose (CSF rhinorrhoea)
Fractured mandible - Imaging?
OPT - Shows all areas except the lower anterior region of the mandible
PA mandible
CT scan - 3D view, more detail
Lower occlusal - anterior
Complications associated with mandibular fractures
Plate infection Delayed/mal/non-union Bone loss Infection Residual trismus Disturbed occlusion Nerve damage - ID/mental
Frontal sinus fracture
Side view = dip in face Bruising Swelling Eye closing CT scan - dent in head
