theme 13 Flashcards by Sophie Lynch

primary survey for assessing maxillofacial injuries

ATLS

ABCDE

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how to assess D in ABCDE

AVPU or GCS (below 8 = coma)

abnormal signs

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sign of increased cranial pressure

pupil dilation

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when is secondary survey carried out

after life threatening injuries dealt with

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sections of secondary survey

extra-oral
intra-oral
functional assessment
radiographic

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what to look for in extraoral exam

laceration
ecchymosis
oedema 
deformity/step deformities
CSF leak
eye injuries
palpation for tenderness
numbness
crepitus

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what to look for in intraoral exam

missing teeth
broken teeth/dentures
lacerations
ecchymosis
step defects in occlusal plane
palpation - tenderness, steps, mobility
numbness

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what to assess in functional assessment

occlusions
mandibular movements
eye movements
nerve injury

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types of soft tissue injury

abrasions
contusions
lacerations
avulsions
animal/human bite
gunshot

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how to assess wound

extent
tissue loss
contamination
foreign body - don't remove
nerve function
vessel involvement 
other structures involved

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how to prevent infection

early closure - even if temporary

if delayed - need to wash out first

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how to avoid dead space in primary closure

close in layer, also reduces scarring

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how to reduce tension in primary closure

undermine edges

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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

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ladder for replacing lost tissue

leave - allow granulation
split thickness skin graft
full thickness graft
local flaps
regional flaps
free flaps

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complications of soft tissue injuries

infection
dehiscence/breakdown
scarring - poor technique, keloid patient
loss of function - nerve injury, structural involvement

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4 principles of treatment of fractures

reduction
fixation
immobilisation
restoration of function

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4 ways to categorise mandibular fractures

site
direct/indirect
description
favourability

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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

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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

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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

1. soft diet, analgesics 2. Elastic intermaxillary fixation with early mobilisation 3. 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