Maxillofacial trauma

Question 1

What is the most common isolated facial bone fracture?

Answer 1

Nasal bone fracture

Question 2

What causes facial fractures most often?

Answer 2

Interpersonal violence and motor vehicle accidents

Other causes include falls, sports, and industrial injuries

Question 3

How does alcohol affect maxillofacial trauma?

Answer 3

Alcohol is an aggravating factor

Question 4

Who commonly gets maxillofacial injuries?

Answer 4

80% are males aged 20 - 35

Question 5

How is energy helpful in understanding the severity of trauma?

Answer 5

Kinetic energy is directly direct related to injury severity and is predicted by 1/2 inertia and v^2.

Question 6

What are the symptoms of a base of skull fracture?

Answer 6

Base of skull fracture (Bone in base of skull. Symptoms include bruising behind the ears, bruising around the eyes and bleeding behind the eardrum.

CSF leak occurs in 20% of cases.

This results in fluid leaking from the nose or the ear.

Question 7

What are the types of head injury associated with contact?

Answer 7

Scalp laceration

Skull fracture

Coup

Epidural haematoma

Subdural haematoma

Question 8

What head injuries are associated with acceleration?

Answer 8

Concussion

Contrecoup

Subdural haematomas

Diffuse axonal injury.

Question 9

How do sinuses protect from brain injuries during facial trama?

Answer 9

The sinuses act like crumple zones to distribute and absorb energy to protect the brain.

Question 10

Which anatomical structures of the face are most commonly injured?

Answer 10

Nose

Lower third of the facial skeleton is more prominent and so it is more commonly fractured. It is also the most common cause for surgical intervention.

Question 11

What causes lower third of the face fractures most often?

Answer 11

Assaults. Lateral forces.

Question 12

The mandible is made of U shaped bone. What should you look for if it is fractured?

Answer 12

Look for contralateral fractures on the other side.

Question 13

How does the the TMJ protect the face from injury?

Answer 13

Mandible articulates with temporal bone at the TMJ which acts as a crumple zone

Question 14

How should cervical spine injuries be managed if they occur with facial fractures?

Answer 14

Stabilize the cervical spine with a rigid collar until the spine injury is ruled out.

ATLS-ABC

Question 15

What are the common features of a frontal bone fracture?

Answer 15

High energy impact

Usually involves the anterior table. Can involve the posterior table as well but that is less common but more significant because it may affect the cranial cavity.

Produces a cosmetic defect

Question 16

How should frontal bone fractures be managed?

Answer 16

Requires joint management by maxillofacial and neurosurgical teams

Question 17

What are the anterior and posterior tables of the frontal bone?

Answer 17

The anterior surface of the frontal bone on the side facing forehead skin and is a part of the sinus.

Posterior table is the other side of the sinus facing the cranial cavity.

Question 18

How should soft tissues and oral cavity be assessed following trauma?

Answer 18

Assess for disfigurement and damage to underlying anatomical structures such as parotid ducts, vessels, and nerves.

Foreign bodies and debris should be removed with lavage

Oral cavity should be checked for tongue laceration, deranged occlusion, IAN damage and parasthesia

Question 19

What midface structures should be assessed following trauma injuries?

Answer 19

Nasal bone, maxilla, zygomatic arch, zygomatic complex, orbit.

Question 20

What causes nasal bone fractures most often?

Answer 20

Main cause is interpersonal violence

Question 21

How do you treat nasal bone fractures prior to surgery?

Answer 21

Assess for asymmetry and mobility clinically

Manage epistaxis

Allow 5-7 days for the oedema to resolve, facilitating precise operative intervention

Question 22

What are the features of zygomatic bone fractures?

Answer 22

Periorbital swelling and ecchymoses

Subconjunctival haemorrhage

Palpable step at the infraorbital margin or lateral brow area

Infraorbital nerve involvement

Depression of the malar eminence

Diplopia is common due to orbital involvement

Question 23

What are the features of orbital fractures?

Answer 23

Medial and inferior walls of the orbital skeleton are exquisitely thin

Commonly involved in zygomatic complex fractures

Also occur as an isolated injury due to a direct blow to the orbit or orbital rim

Assessment of the eye is paramount when these injuries occur

Subconjunctival and periorbital haematoma are common

Diplopia occurs when the orbital muscles and soft tissues are trapped

Question 24

What are the features of midface fractures?

Answer 24

Facial swelling with bilateral periorbital haemorrhages (raccoon signs)

Flattening and elongation of the midface

Dish face deformity

Test mobility of the maxilla

Patients often complain of malocclusion

Question 25

What are le fort fractures?

Answer 25

Often includes any array of fronto-orbital, zygomatic, and nasoethmoidal fractures in combination with maxillary injury.

Question 26

What is the difference between le fort 1, 2 and 3 injuries?

Answer 26

Le fort 1 = Maxilla involved up to the maxillary sinus

Le fort 2 = sinuses involved

Le fort 3 = the zygomatic bone involved as well as the sinuses.

Question 27

What are the types of fractures?

Answer 27

Greenstick (Occurs in children)

Simple or closed

Comminuted

Compound

Pathological

Question 28

What are the most common sites of fracture in the mandible?

Answer 28

Condyle

Body

Angle

Question 29

What are the symptoms of a fractured mandible?

Answer 29

Pain

Swelling

Limited mouth opening

Mental parasthesia

Deviation of the mandible

Step deformity

Mobility at site

Haematoma

Question 30

What are the management methods of a mandibular facture?

Answer 30

Closed reduction: IMF screws, eyelet wires, bonded brackets

Question 31

What are the benefits and limitations of using closed reduction over surgery?

Answer 31

Less expensive

Does not traumatize vascular envelope

Period of immobilization (difficulty eating/weight loss)

Requires intact dentition

Requires patient compliance

Risk damage to roots
Gingivae inflammation/ poor oral hygiene

Question 32

What are the benefits and limitations of using open reduction and internal fixation?

Answer 32

More expensive

Intra or extraoral approach

Periosteal stripping disturbs vascular envelope

Direct visualisation and reduction of fracture

Earlier return to normal function

Better nutrition

Better oral hygiene

Question 33

What are the things to look out for with paediatric mandibular fractures?

Answer 33

Bony growth centres and developing tooth buds

Restoration of mandibular continuity important for function and also future craniofacial development

Conservative management if minimally displaced

TMJ - growth centre in children so beware of late sequlae (ankylosis)

Question 34

How does edentulism affect the mandible?

Answer 34

Causes atrophy

Individuals develop comorbidities

Poor healing

Poor bone stock

Question 35

How should people with mandibular fractures that have undergone surgery be treated post surgery?

Answer 35

Soft diet important in patients who have undergone open reduction internal fixation

Patients placed in intermaxillary fixation need to be advised about nutritional issues and oral hygiene instructions

Postoperative radiographs and clinical assessment to check for:

• fracture healing
• fracture segment alignment and status of occlusion

Question 36

How does mechanism of injury affect the treatment?

Answer 36

Mechanism of injury important in history taking

Patterns of injury from type of mechanism deployed

Injury prevention as part of continuum of care – mouthguard, helmets.