Maxillofacial Trauma Flashcards
What are the advanced trauma life support principles?
A- airway plus C- spin control (assume all trauma patients have a broken neck).
B- breathing
C- circulation plus haemorrhage control
D- disability, based on the GCS.
What are the signs and symptoms of a mandible fracture?
Sublingual haematoma- lump in the FOM.
Two-point vertical mobility- grab the jaw with two hands and move both bits up and down and see if they move out of line.
Abnormal sensation contralateral to side of injury.
Pain in contralateral sign of injury.
Numbness ipsilateral to trauma site, that cannot be explained b direct injury to the nerve.
What radiographs might you want to take if you suspect a mandibular fracture?
OPT and Postero-anterior mandible.
Always take 2 radiographs.
If you suspect a mandibular fracture, what would you do next?
Already taken radiographs.
Tell the patient to stop eating- they may require surgery.
Give them pain relief- they can have this, even if they’re fasting.
Antibiotics for open fracture- amoxicillin or metronidazole.
Liquid diet.
Immediately phone OMFS and explain situation.
What signs and symptoms would suggest a mid-face fracture (including zygoma)?
Epistaxis without a blow to the nose (bleeding from the nose).
V2 numbness without a direct blow to the nerve.
Subconjunctival bleed- turns the white bits of your eye red.
Midface mobility.
Malocclusion that wasn’t present before the injury.
Surgical emphysema around the eye.
Swelling after nose blowing.
Diplopia- double vision.
Change in appearance.
CSF running out of their mouth.
Describe the different Le fort fractures.
Le Fort I- horizontal maxillary fracture which separates the upper teeth from the upper face.
- Fracture line runs through the alveolar ridge, lateral nose and inferior wall of the maxillary sinus.
- “floating palate”
Le Fort II- pyramidal fracture, where the base of the pyramid is at the upper teeth and the tip is at the naso-frontal suture at its apex.
-fracture arch passes through the posterior alveolar ridge, lateral walls of maxillary sinuses, inferior orbital rim and nasal bones.
- “floating top jaw”
Le Fort III- transverse fracture line passes through nasofrontal suture, maxillo-frontal suture, orbital wall, and zygomatic arch/zygomaticofrontal suture.
- highest rate of CSF leak.
- “floating face”
If someone has a mid face fracture, what would you do in general practice?
Take 2 x-rays
- OPT and occipitomental.
No antibiotics required.
Call OMFS- explain clinical findings.
No nose blowing for at least 6 weeks.
Soft diet for comfort.
Give warning about retrobulbar bleed- bleeding behind the eye balls.
What signs and symptoms would suggest an orbital fracture?
Eyes look sunken in
Diplopia
Can you see?
Infra-orbital paraesthesia
What action would you take if yous suspect someone has an orbital fracture?
Don’t take any x-rays.
Discuss with OMFS DCT on call.
Tell them not to blow their nose and do not give them antibiotics.
What is the referral route to OMFS?
Contact OMFS DCT on call
Have patient’s details ready- CHI, phone numbers, age.
Any relevant medical history.
When was the last time they had something to eat or drink?
Let them know that OMFS will be in touch.
Do not send a patient to OMFS without discussion with someone in the department first.
What anatomy is important if the medial wall of the orbit is damaged?
Medial wall- medial rectus muscle, lacrimal dust and sac, medial cantal ligament, ethmoid sinus, cribriform plate.
- Damage to this area will mean the patient cannot move the eye ball medially, the patient will complain of dry eyes and infection.
What anatomy is important if the superior aspect of the orbit is damaged?
Inferior orbital fissure
- Occulomotor nerve, trochlear nerve, abducens, branches of the ophthalmic nerve (nasociliary, lacrimal and frontal branches), ophthalmic veins.
What anatomy is important if the inferior aspect of the orbit is damaged?
Inferior orbital fissure-
- Infraorbital nerve, infraorbital vein, infraorbital artery, zygomatic nerve.
What are the signs and symptoms of a malar (zygomatic) fracture?
Subconjunctival ecchymoses
Subconjunctival haemorrhage
Periorbital bruising and swelling
Step deformity
Sensory deficits- damage to infraorbital foramen will manifest in numbness of the upper lip, cheek and nose.
Diplopia/visual impairment- oculomotor nerve supplies muscles in the eye part from lateral rectuis and oblique muscles (these are supplied by abducens)- patient will be unable to move their eye and have double vision.
Subcutaneous emphysema
Epistaxis- blood will drain from the maxillary sinus into the nasal cavity via the semilunar hiatus.
Limited mouth opening- fracture of the zygoma will impinge on the coronoid process.
If you suspect someone has a zygoma fracture, what would you want to examine?
Palpation for irregularities of supraorbital ridge.
Palpation for irregularities of infraorbital ridge and zygoma.
Palpation for zygomatic arch.
Manoeuvre to ascertain motion in maxilla.
Can you move your eyeball?
Ask them to open their mouth as wide as they can- do they have trismus?
What x-rays would you take if you suspect a facial fracture?
Midface- occipitomental
Posterior mandible- postero-anterior mandible.
Mandibular condyles- reverse Townes.
What radiographic signs on an occipitomental radiograph might suggest a zygomatic fracture?
Radiopacity of the maxillary sinus- filled with blood.
Step deformity in the floor of the maxillary sinus.
Slippage of the orbital contents from the orbit into the maxillary sinus space.
Clinicallly the eye will be retruded in the face.
What is the definitive management of a malar fracture?
Review when swelling subsided
Radiographs +/- CT
- Occipitomental radiograph.
Informed consent
Closed reduction +/- fixation
Open reduction + internal fixation (with plates)
What are the signs of airway obstruction?
Stridor on inspiration
What manoeuvres might you do to improve the airway in OMFS trauma?
Head tilt, chin lift
Jaw thrust
Apply nasopharyngeal airway or oropharyngeal airway
When assessing bleeding in OMFS trauma, what would you want to look for?
Major blood vessels in the head and neck- carotid artery, jugular vein.
Minor blood vessels- these can be a lot more difficult because they are very deep in the head- lingual artery, maxillary artery, pterygoid plexus.
During your secondary survey of the patient, what would you want to look for?
Looking at smaller injuries which are not life threatening.
Pupils, eye movements, pain, haemorrhage, pain, Conjunctival chemises, proptosis, visual acuity, numbness in V1 or V2.
Look at the facial skeleton- assess mandible, mid face, orbit and nose.
- Numbness, mobility, visual acuity, eye movements, symmetry, CSF leak.
What aspects of the soft tissues would you wish to examine in an OMFS trauma case?
Soft tissue injuries that involve the cranial nerves, on top of facial fractures, gross contamination of soft tissue injuries.
Injuries to special reas- eyes, lips, through and through nose/ear.
Neck injuries through platysma.
What are the key aspects to taking a history in OMFS trauma?
Was the trauma blunt or sharp?
When did it happen?
Any other injuries- i.e. head/spine?
Have you taken drugs/alcohol/smoking?
PMH
Allergies
Social history
