theme 13 Flashcards
primary survey for assessing maxillofacial injuries
ATLS
ABCDE
how to assess D in ABCDE
AVPU or GCS (below 8 = coma)
abnormal signs
sign of increased cranial pressure
pupil dilation
when is secondary survey carried out
after life threatening injuries dealt with
sections of secondary survey
extra-oral
intra-oral
functional assessment
radiographic
what to look for in extraoral exam
laceration ecchymosis oedema deformity/step deformities CSF leak eye injuries palpation for tenderness numbness crepitus
what to look for in intraoral exam
missing teeth broken teeth/dentures lacerations ecchymosis step defects in occlusal plane palpation - tenderness, steps, mobility numbness
what to assess in functional assessment
occlusions
mandibular movements
eye movements
nerve injury
types of soft tissue injury
abrasions contusions lacerations avulsions animal/human bite gunshot
how to assess wound
extent tissue loss contamination foreign body - don't remove nerve function vessel involvement other structures involved
how to prevent infection
early closure - even if temporary
if delayed - need to wash out first
how to avoid dead space in primary closure
close in layer, also reduces scarring
how to reduce tension in primary closure
undermine edges
how to reduce chance of inversion in primary closure
ensure wound edges well apposed + slightly everted
invert due to contraction across + along length due to collagen + fibroblast mutations
ladder for replacing lost tissue
leave - allow granulation split thickness skin graft full thickness graft local flaps regional flaps free flaps
complications of soft tissue injuries
infection
dehiscence/breakdown
scarring - poor technique, keloid patient
loss of function - nerve injury, structural involvement
4 principles of treatment of fractures
- reduction
- fixation
- immobilisation
- restoration of function
4 ways to categorise mandibular fractures
site
direct/indirect
description
favourability
signs and symptoms of angle or body fracture
Pain, bleeding/swelling(haematoma), deformity, mobility of bone ends, deranged occlusion, loose teeth (if the fracture is in the alveolar process), paraesthesia
signs and symptoms of condylar fracture
Pain, bleeding/swelling(haematoma), deformity, mobility of bone ends, deranged occlusion, loose teeth (if the fracture is in the alveolar process), paraesthesia
bilateral - early posterior contacts
unilateral - affected side early bite, other side openbite
options to treat dentoalveolar fracture
flexible splint
plating
flowable composite capping - space maintenance + bone maintenance
radiographs to assess mandibular fracture
DPT + PA +/- townes
are fractures regarding tooth bearing area of jaw classed as open or closed
open
points of weekness of mandible
third molar
socket of canine
condylar neck
mental foramen
4 types of mandibular fracture
simple
wedge
segmented
comminuted
3 options for managing mandibular fractures
conservatively
mandibulomaxillary fixation - old school
miniplate fixation
considerations when assessing condylar fracture
location amount of vertical reduction of ramus degree of angulation of fragment degree of laxation of condylar head out of fossa fragmentation pattern association with other mandibular injuries dental occlusion foreign body in TMJ
4 indications to use load bearing osteosynthesis
atrophic edentulous fractures
comminuted fractures
defect fractures
other complex mandibular fractures
options to conservatively manage fractures
- soft diet, analgesics
- Elastic intermaxillary fixation with early mobilisation
- Open reduction & antibiotics (not no fixation)
when would you use conservative management of fractures
non displaced, non-mobile, normal occlusion,
compliant patient agrees for follow ups
patient refuses operative treatment
conditions making ORIF difficult - medically unstable
plates/screws unavailable
what is load bearing osteosynthesis
plates that bear forces of function at the fracture site
what is mandibulomaxillary fixation
rigid fixation in dentate patient - fixation of occlusion
indications to remove teeth in line of fracture
tooth luxated and/or interfering with reduction
tooth fractured
gross caries/perio
mobility which would not contribute to stable occlusion
existing pathology
principles of ORIF
passive action - don’t want to create tension
plates at sites of tension
3 contraindications for ORIF
gross comminution
infection
bone loss
complications of healing
malunion/non-union failure of fixation infection ankylosis necrosis
how to manage infection
exposure, debridement, sequestrectomy temporary fixation recon plate same stage grafting plate removal
mid 1/3 face fractures include which bones mainly
nasal, maxilla, zygomatic bones
when are nasal fractures treated
if aesthetic or functional problem - so not diagnosed radiographically
treatment of nasal fractures
MUA if within 2 weeks + splint
septo/rhino-plasty if over
what are buttresses
thicker areas of bone that face is suspended from - canine, zygomatic, middle third
signs of zygomatic arch fracture
pain from cheek
facial flattening
restricted opening + lateral excursion
what radiographs are used to assess mid third fractures
occipital-mental views, OM10 + 30
management for zygomatic arch fracture
Gillie’s approach/Rowe’s elevator
or intra-oral approach
~5 days when swelling reduced but bone not begun to heal
what is a zygoma tripod fracture
across all 3 sutures - infra-orbital, Z-F, zygomatic
+/- orbital involvement
+/- antral involvement
what are le fort fractures
transverse fractures involving the obital, zygomatic & nasal bones
signs of zygoma fracture
pain peri-orbital ecchymosis/oedema/altered facial profile subconjunctival haemorrhage step deformities at IO rim/ZF/arch parasthesia diplopia/enophthalmos
management of zygoma fracture
only act is aesthetic or functional problem, otherwise conservative
reduction- poswillo hook, gillies, intra-oral, rowes elevator
fixation - ZF via lateral eyebrow, zygomatic buttress via sulcus incision, IO rim via skin crease/transonjunctival
signs of le fort fracture
face flattening/elongation bilateral facial + periorbital oedema epistaxis anterior or lateral open-bite/malocclusion ecchymosis in maxillary vestibule parasthesia of midface
management of le fort fractures
ORIF
how to diagnose le fort fracture clincally
manipulation of maxilla to see what moves with it
what is an orbital floor fracture
blow out fracture caused by blunt trauma
orbital contents into maxillary sinus
