W17 62 maxillofacial trauma Flashcards
How do you manage maxillofacial bleeding?
‘Permissive hypotension’ - managing low blood pressure to reduce bleeding
External bleeding controlled with clips/sutures/pressure (lots of blood supply so area heals well)
Manual reduction of displaced mid-face fractures
Early intubation (securing a definitive airway)
What does early intubation (securing a definitive airway) allow?
Manual reduction of fractures
Mouth props to reduce fractures
Oral packing
Nasal packing
Surgical litigation of external carotid/ethmoidal arteries (rare)
Transfer for interventional radiology and embolisation
What are the issues with nasal packing?
Problems since midface fractures often preclude midface packing due to the risk of base of skull injuries, but once a base of skull injury has been excluded, nasal fractures and nasal epistaxis can be safely packed.
Initially if haemorrhage is major and potentially life-threatening, then nasal packing carefully would be the first point of call to enable scanning to ensure basal skull fractures are excluded.
What should you examine in the midface region?
Look from in front - for symmetry of cheekbones in terms of eye position
Hypoglobus? One eye lower than the other
Symmetrical projection of cheekbones
Nose appearing straight?
Loss of projection or volume of eye
Any step deformities around eye socket indicating a zygomatic fracture
Grab hold of their top teeth and maxilla stabilising on bridge of nose or zygomatic frontal sutures giving the maxilla a wobble to see if any movement which would indicate a LeFort fracture.
Check the occlusion
Most common locations for mandible fractures?
Condylar process
Angle
Body
Symphysis
Ramus, coronoid process, alveolar process
How do you treat mandibular fractures?
Aim is to return to function early, so use mini titanium plates with screws that hold fragments together
Plates are titanium, stay in for life, relatively light. Means they can be deformed, bent and broken. They are there to position the fractures together, to enable the body to do its own work and heal them.
Load bearing osteosynthesis.
Is A, a screw that screws all the way through the bone, better than B, a screw that goes halfway, for treatment of fractures? (PG606 IMG)
A is stronger with the screw going all the way through the bone and binds to plate
But more issues to drill further and need external incisions too
Pick based on the nature of the structure and the patient, eg are they immunocompromised, responsible, and follow good post-op advice?etc
Where do zygomatic bones usually fracture? (PG606 IMG)
The frontal zygomatic suture, Infraorbital margin and maxillary buttress (1,2,3 on image).
What do zygomatic fractures usually affect?
Orbital floor and roof of maxillary sinus
What are the different LeFort fractures? (IMG PG606)
LeFort 1 - from piriform aperture back to the pterygoid plates
LeFort 2 - across bridge of nose, medial orbital walls and floors and down back towards the pterygoid plates
LeFort 3 - complete destruction of the facial skeleton from the cranial vault
How should you clinically assess the eye socket/orbital fractures?
Visual acuity (ask about refractive error and correct)
PERLA (pupils equally reactive to light and accommodation?)
Periorbital bruising/subconjunctival haemorrahge
Numbness over cheek
Restricted eye movements/diplopia
Forced duction test - grab eye and move it, done intraoperatively, to check that the eye is moving freely
Enophthalmus - is the eye sent back or down
Also think about: nasolacrimal dysfunction eg epiphora (excess tears), presence of foreign bodies, globe rupture/injuries
What are some initial investigations for orbital fractures?
Plain radiographs
Mirrors and pointers with grids to dissociate right and left eyes
Pitfalls
What can plain radiographs of orbital area show?
May be useful for ruling out Co-existing zygomatic complex fractures if suspected guide surgery
Suspicion of orbital floor fracture may be raised by an opacified antrum and/or ‘teardrop sign’ (fat in teardrop shape)
Useless for orbital fractures because orbital floor is obscured by the inferior orbital ring
What might mirrors and pointers show?
Are eyes moving in synchrony or do they have binocular diplopia
Aim is to use titanium plates to re contour and reproduce the eye socket to support the globe better and free up any muscle entrapment
What is binocular diplopia and what can it indicate?
Double vision when looking with both eyes, indicating that they might have a mechanical restriction of the movement of the eye as a result of the fractures
