Facial Fractures

This presentation deals with the management of Facial trauma with the main emphasis on Nasal bone fracture.

1. NASAL AND FACIAL FRACTURES CONSULTANT : DR VIKAS MALHOTRA MODERATOR : DR KARISHMA PRESENTOR : DR AVINAV

2. NASAL FRACTURES 25-75 lb /in 2 force is required. Refracture rate – 5% 15-30 years Causes : assaults, contact sports, adventurous leisure   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

3. CLASSIFICATION : Nature of injury Extent of injury Pattern of the fracture   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

4. NATURE OF INJURY : Laterally applied force injuries – 66% Frontal injuries – 13%   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

5. EXTENT OF DEFORMITY : Grade 0 : bones perfectly straight Grade 1 : <½ of width of bridge of nose Grade 2 : ½ to 1 width of bridge of nose Grade 3 :> 1 width of bridge of nose Grade 4 : almost touching the cheek   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

6. PATTERN OF FRACTURE : Simplest form : Depressed nasal bone, nasal septum not involved Severe form : both nasal bone and septum involved Clinically : depressed nasal bone with tenderness and crepitus 1. CLASS 1 FRACTURES : CHEVALLET FRACTURE   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

7. 2. CLASS 2 FRACTURE : JARJAVAY FRACTURE Associated with cosmetic deformity Involves the # of frontal process of maxilla and septal structures Ethmoidal labyrinth and adjacent orbital structures remain intact   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

8. 3. CLASS 3 FRACTURES : NASO ORBITO ETHMOID FRACTURE High velocity trauma Pig like appearance Two categories – Type 1 : anterior skull base, posterior wall of frontal sinus, optic canal remain intact Type 2 : disruption of posterior frontal sinus wall, multiple fracture of roof of etmoid and orbit.   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

9. CLINICAL PRESENTATION : History How ? When ? Nasal obstruction Change in appearance Epistaxis Orbital trauma signs Dental injury Skull base damage   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

10. Examination : Any deformity ? Mobility/crepitus/tenderness Generalised swelling Laceration Fracture/ haematoma /abscess/ perforation   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

11. INVESTIGATION : XRAYS CT scan Csf leak : TREATMENT : 80% no active treatment topical vasoconsrtictor drops Surgical intervention – significant cosmetic deformity or nasal obstruction   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

12. METHODS OF REDUCTION : CLOSED REDUCTION : U/L or B/L # of nasal bones # of nasal septum with deviation <1/2 of width of nasal bridge   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set (a) Howarth’s elevator; (b) Ashe’s forceps (septum); (c) Walsham’s forceps (nasal bones)

13. Determining depth of insertion of instrument into nasal cavity.   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

14. OPEN REDUCTION (Verwoerd) B/L # with dislocation of nasal dorsum and septal deformity Infraction of nasal dorsum # of cartilaginous pyramid + dislocation of upper laterals   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

15. COMPLICATIONS : Poor cosmetic result Nasal obstruction Epistaxis Septal complication– haematoma , abscess, perforation   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

16. FACIAL FRACTURES : 10% of all A/E are related to facial injuries Immediate airway assessment is required RTA, attempt suicide, sport injuries, physical violence mechanism of injury provides insight on possible degree and extent of injury. PRIMARY CARE : Airway Breathing Circulation Disability Exposure   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

17. MANDIBULAR FRACTURES : SURGICAL ANATOMY : # occurs where the bone is relatively thin –   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

18. Signs and symptoms : # of body, angle and symphysis Bony step deformity Deranged occlusion Pain Sublingual haematoma Mobile teeth in fracture line Anesthesia in lower lip trismus # of condylar neck : TM joint tenderness Trismus Lateral open bite Anterior open bite   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

19. CLOSED REDUCTION TECHNIQUES Intact dental arch : leonard button Incomplete dental arch : Arch bars Intermaxillary bone pins   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

20. EXTERNAL FIXATION Cast silver splint Gunning splint   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

21. INTERNAL FIXATION Intra oral incision : Extra oral incision :   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set CONDYLAR NECK FRACTURES Functional adaptation Neuromuscular rehabilitation Altered condylar mechanics

22. FRACTURES OF MAXILLA : INTRODUCTION : Midfacial # - lateral (zygomatic) central (maxillary, nasal, nasorbitoethmoid ) SURGICAL ANATOMY : low energy injuries : Le Fort Classification High energy injuries :   S ource: Cummings Otolaryngology  - Head and Neck Surgery, 3-Volume Set: Expert Consult:

23. Kim, Hak & Kim, Seong & Lee, Hyun. (2017). Management of Le Fort I fracture. Archives of Craniofacial Surgery. 18. 5. 10.7181/acfs.2017.18.1.5.

24. SIGNS AND SYMPTOMS : Epistaxis Circumorbital ecchymosis Facial oedema Surgical emphysema Lengthening of face Infraorbital anaesthesia MANAGEMENT : Emergency treatment Reduction Fixation : ( IMF, EF, IF )   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

25. Severe multilevel Le Fort fracture with typical ‘panda eyes’ 3D CT reconstruction demonstrating vertical, horizonal and transverse disruption to the entire craniofacial skeleton   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

26. ZYGOMATIC COMPLEX FRACTURES : SURGICAL ANATOMY : Frontozygomatic Zygomaticomaxillary buttress Inraorbital rim Zygomatic arch zygomaticosphenoid   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

27. SIGNS AND SYMPTOMS : Subconjunctival haemorrhage , eyelid oedema , restricted eye movement Step deformity of infraorbital margin, tender frontozygomatic suture Arch # : palpable depression and limited mouth opening Sensation of cheek altered IMAGING : Occipitomental Xrays CT scan HESS charting   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

28. MANAGEMENT : Minimally displaced # - conservative Displaced # - reduction + fixation 1. Gillies temporal approach – Medially displaced body #, zygomatic arch #   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

29. 2. Poswillo Hook – Posteriorly displaced # 3. Dingman – Medially displaced body #   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

30. 4. Intra oral or Keen – medially displaced #, arch # 5. Coronal – laterally displaced arch #   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

31. POST OP CARE : First 12 hours : don’t blow nose Watch for retrobulbar haemorrhage : Decreased visual acuity Diplopia Opthalmoplegia Proptosis Tense globe Dilated pupil Loss of direct light reflex   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

32. ORBITAL FLOOR FRACTURES : Blunt trauma to the globe or adjacent bone Signs and symptoms : Enopthalmus Hypoglobus Supratarsal hollowing Hooding of the eye Palpebral fissure narrowing Infraorbital nerve deficit Trap door phenomenon   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

33. Imaging : CT Management : exploration and repair Grafts used – PDS (polydimethylsiloxane) Titanum alloplasts   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

34. NASO-ORBITO-ETHMOID COMPLEX # Markowitz et al classification : TYPE 1 : single large fragment bearing the canthal ligament TYPE 2 : fragmentation of the central fragment, medial canthal ligaments attached to bone TYPE 3 : communition of the central ligament with no bone attached to canthal ligament   S ource: Cummings Otolaryngology  - Head and Neck Surgery, 3-Volume Set: Expert Consult:

35. Signs and symptoms : Loss of nasal projection and tipping tip of end of nose Splaying of nasal root and telecanthus Blunting of canthal angle Management : Type 1 : miniplates through coronal flap, intra orally and eyelid incision Type 2 and 3 : miniplates through transnasal canthopexy   Elbarbary , Amir S. and Ahmed Ali Hassan. “Medial canthopexy of old unrepaired naso -orbito-ethmoidal ( noe ) traumatic telecanthus .”  Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery  42 2 (2014): 106-12 .

36. ROCHA, J. L. S.; CAVALIERI-PEREIRA, L.; BRANCHER G. Q. B.; ALTAFIN, L.; CEREZETTI, L. & MIRANDOLA, C. Treatment of naso -orbito- etmoidal Type III fracture in adolescents - Case report. Int. J. Odontostomat ., 14(2):167-171, 2020. Pre op Post op

37. UPPER FACIAL THIRD # INVOLVING FRONTAL SINUS : Anterior table # - no cosmetic deformity - managed conservatively. Displaced # - reduction and fixation Posterior table # - neuros x opinion, obliterative procedure, cranialization Soft tissue injuries : Facial wound – close early Meticulous debridement Facial nerve Chloramphenicol eye oint .   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

38. PAEDIATRIC FACIAL INJURIES Soft tissue injuries : Resorbable suture Cyanoacrylate glue Injured anterior teeth : # teeth Moblie teeth – slint to adjacent teeth Exposed pulp – calcium hydroxide paste Avulsed - reimplant   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

39. # of facial bone : Reduction and fixation Plates with short screw, remove >3-6 months Condyle # – conservative Medial canthi dissection – acrylic button   S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

40. Reference : Links:   Elbarbary , Amir S. and Ahmed Ali Hassan. “Medial canthopexy of old unrepaired naso -orbito-ethmoidal ( noe ) traumatic telecanthus .”  Journal of cranio-maxillo-facial surgery : official publication of the European Association for Cranio-Maxillo-Facial Surgery  42 2 (2014): 106-12 . Kim, Hak & Kim, Seong & Lee, Hyun. (2017). Management of Le Fort I fracture. Archives of Craniofacial Surgery. 18. 5. 10.7181/acfs.2017.18.1.5. ROCHA, J. L. S.; CAVALIERI-PEREIRA, L.; BRANCHER G. Q. B.; ALTAFIN, L.; CEREZETTI, L. & MIRANDOLA, C. Treatment of naso -orbito- etmoidal Type III fracture in adolescents - Case report. Int. J. Odontostomat ., 14(2):167-171, 2020. Cummings Otolaryngology  - Head and Neck Surgery, 3-Volume Set: Expert Consult: S ource: Scott - Brown's  Otorhinolaryngology: Head and Neck Surgery 7Ed: 3 volume set

41. THANK YOU