Facio maxillary injuries

Faciomaxillary trauma
Classification Diagnosis and Management

1. Facio -maxillary injuries classification – diagnosis- management Presentor:Dr . Sivasankar Post Graduate General surgery

2. Introduction Maxillofacial trauma Soft tissue,Skeletal and Visceral Injuries Nasal, Auditory, Mandibular or Ocular Function Interfered Disfigurement & Disability  Psychological Trauma

3. Etiology Motor Vehicle Collision Assault Falls Gun Shot wounds and War injuries Sports Accidents Occupational – Industrial Mishaps

4. Faciomaxillary trauma associated with Airway compromise Blindness Concomitant Traumatic Brain injury C- Spine injury Poly trauma

5. Phases of Facio maxillary trauma Management Emergency Care Initial Care Definitive Care Reconstruction

6. Phases of Facio maxillary trauma Management – emergency Care Phase Preserve Airway or Establish if Compromised Check for Breathing and Ventilate mechanically if need Control Bleeding and ensure Circulation C-spine Stabilization Control Life threatening injuries associated Head Injuries Chest Injuries Fractures Intra abdominal Bleeding

7. Airway management Complications: Airway compromise Haemorrhage Trismus Cervical spine injury Pneumoencephalus Injury to oesophagus Subcutaneous emphysema and pneumomediastinum

8. SIMPLE AIRWAY STRATEGY Chin lift, Jaw thrust, Administration of 100% oxygen. Placement of an oropharyngeal , nasopharyngeal airway or LMA , in inadequately breathing patients, ventilation with a self-inflating bag.

9. Definitive airway 1. Direct laryngoscopy and tracheal intubation. 2. Video laryngoscopy and intubation. 3. Fibre -optic tracheal intubation. 4. Lightwand -guided tracheal intubation ATLS guidelines suggest that airway management provider should proceed with the method of intubation with which they are most proficient.

10. Phases of Facio maxillary trauma Management – INITIAL Care Phase Emergency care of Stabilised patient Initial Stabilisation of Fractures Debridement & Dressing of Soft tissues Elective Surgical Airway Physical Exam & History Lab tests Complete H&N Examn . Diagnosis of Faciomaxillary Injuries

11. History History related to Head Injury History of blindness/ Diminished Vision History of hard of hearing History of Double Vision History of Numbness or Tingling History of Pain in Jaw movements

12. Inspection Foreign bodies Facial Asymmetry Nasal Deviation Septal Hematoma, CSF Rhinorrhea CSF Otorrhea , Blood in EAM Malocclusion and Loss of teeth Battle Sign and Raccoon Sign

13. Battle sign & Raccoon Sign Suggestive of Basilar #

14. CSF Otorrhea and Rhinorrhea

15. Palpation Step Defect Crepitus – Bone “give away” Subcutaneous Emphysema Mobility

16. Cranial Nerve Examination Visual and Pupillary changes CN II Abnormalities of Ocular Movements CN III IV VI Motor Function of Facial Muscle CN VII Muscles of mastication CN V Sensation facial area CN V

17. Classification Maxillofacial trauma Ocular /Nerve Injuries Soft Tissues Dentition Skeletal

18. Soft tissue injuries

19. Soft tissue injuries Contusion Abrasive injuries Lacerations Avulsive injuries Accidental tattoo Puncture wounds

20. Accidental tattoo (Dermal imbedded particles) Should be removed promptly from abrasion Fixation occurs in 24 -48 hrs Scrub with stiff bristle brush to remove

21. Soft tissue Facial Injuries - General Rich Blood Supply – Large Laceration survive with Small Pedicles “ Good Wash, Limited Debridement , Apt Antibiotics ” Minimal Tissue loss – Primary Closure <24 hours Suturing –in layers Deep layers – Vicryl ( Braided Absorbable)- Dead Space Elimination Superficial – Ethilon ( Monofilament) – Tension Free- Reduce Scarring Remove Suture 3-5 days Apply Sunscreen over Scar site for 1 yr.- prevent Skin Discoloration

22. Soft Tissue Facial Injuries- Lip Fibres of Orbicularis Oris Run transverse – gives FALSE Appearance of Avulsion Survey: Oral Mucosal Injuries/ Foreign Bodies Good Wash, Primary Closure (Mucosa [Avoid Salivary Contamination] & Skin) Suturing by Alignment Vermilion Border Gram NEGATIVE ANAEROBES Cover

23. Soft Tissue Injuries- Avulsive Faciomaxillary Injuries MVC Impact/ GSW close Range- Full Thickness tissue Loss Asso . With Hypovolemic Shock, Airway Impairment Serial Saline Dressing Parallel (from ABC to hemodynamic Stability) Serial Wound Debridement to address Necrosis and evolving tissue loss Reconstruction ( tissue transfer- Local/ Regional/Free Flap)

24. Skeletal Injuries - FACE

25. Nasal Fractures MC facial Fracture Nasal Deformity in Laterally Displaced fractures- Inspirational Difficulty Posterior Displacement with Extension to Frontal And Ethmoid Bones Cl/F: Facial Edema, Ecchymoses , Bony Crepitus, nasal deformity, Epistaxis

26. Nasal Fractures Nasal Mucosa has Rich blood supply : Hemorrhage- Hematomas Risk Septal Hematoma – Rx – drainage (to prevent Septal Necrosis, Perforation, Saddle Nose Deformity.) Epistaxis – Nasal Packing, Baloon compression, LA+ Adrenaline

27. Nasal packing

28. Nasal Fractures - Management CT is IMAGING OF CHOICE as it defines anatomy and severity of # better Closed Reduction under LA – Simple Nasal #, Open Reduction under GA – Open #/Nasal retrusion , Persistent Deformity

29. Naso -Orbit-Ethmoid # Marcowitz and Mason Classification based on whether the medial canthal tendons attached the central fragment. Type I injury, - medial canthal tendon attaches a single-segment central fragment (A). Type II injury - central fragment is comminuted , with the medial canthal tendon attached (B). Type III injury - MCT is separated with the comminuted central fragment

30. Naso -Orbit-Ethmoid #   Re attachment of MCT significantly impacts the facial function and appearance.   Transnasal wiring achieved after adequate exposure via coronal incision, and surgeons needed to drill two (for unilateral injury) or four holes (for bilateral injury) in medial orbital wall reconstruction, which must accord to the position where the MCT normally attaches

31. Maxillary Fractures LeFort I – (Guerin fractures/floating maxilla) Horizontal #, Oral- located above roots of tooth, Maxillary part- Mobile LeFort II -Pyramidal Outline, Nasal bone fracture LeFort III – suprazygomatic fracture Complex , Cranio Facial Dissociation, Orbit fracture Substantial Bleed from Nose or/and Oral cavity NG tube is contraindicated

32. II II I III

33. Investigation: CT scan with 3D reconstruction

34. MANAGEMENT Open reduction and intermaxillary fixation should be performed to establish correct occlusion Followed by rigid fixation at the piriform rims and zygomaticomaxillary buttress

35. Zygoma Fractures Tripod # - Zygomatico Maxillary Complex; Quadramalar # - ZMC+Sphenoid 4 principle fracture lines Lateral orbital rim Inferior orbital rim Zygomatic arch Zygomatico maxillary buttress

36. Cl/f: Infraorbital nerve trap – Paraesthesia of I/L cheek Periorbital ecchymosis and Edema. Facial Emphysema – secondary to Maxillary sinus disruption. Loss of Malar prominence Trismus - Zygoma impinges on coronoid process Bone Step Deformity – Zygomatico Frontal suture, Zygomatic arch, inferior orbital Rim

37. Ophthal Consult to rule out globe injury before Surgical intervention. CT is IMAGING OF CHOICE as it defines anatomy and severity of # better: layering of blood in maxillary sinus, Tripod # , soft tissue air emphysema Non displaced # - Conservative ; Displaced # -ORIF

38. MANAGEMENT - surgical fixation

39. Mandibular Fractures 2 nd MC Facial #. 10% Asso . With Head and c spine injuries. Muscles attached to Mandible contract to distract the fracture segments. Inferior Alveolar Nerve trapping. Cl/F: Malocclusion of teeth, trismus . Asso . Dental injuries causes bleeding – sublingual hematoma

40. Investigations OPG Imaging of Choice; CT images defines Suture lines & segments. 3D reconstruction of fracture helps in surgical planning.

41. Reduction and fixation 1. Closed reduction is done by manual manipulation of the teeth or gradual reduction by elastic traction done, e.g. simple and undisplaced fractures can be reduced by closed method. 2. Open reduction is done by direct vision, i.e. by exploration of fracture (e.g. widely displaced, multiple fractures are reduced by open method).

42. Orbital Fractures High force to thin orbital bones – “Blow Out” Fashion Floor > Medial wall of orbit often fractured. Soft tissue emphysema due to Maxillary Sinus involvement. Muscle Entrapment – Inferior Rectus and Inferior Oblique muscle involvement – Diplopia, upward gaze restriction in I/L eye. Globe injuries like corneal abarasion , hyphema , Globe rupture. Exophthalmos initially followed by enophthalmos after edema settles, Epistaxis. Coronal CT useful in defining soft tissue details and fractures.

43. Ocular Injuries MC cause of monocular blindness Blunt/ Penetrating/ impalement / MVC Airbag deployment Asso . with Orbit #- so Ophthal . Consult routine Usually Missed Blunt trauma asso . Ocular Injuries can be picked in Ophthal . examn . VA, Light perception and projection of Injured and Uninjured be Mandatorily documented.

44. Cl/F: Orbital pain,visual changes, eno - /exophthalmos, hyphema , decreased Eye movments CT scan to assess Soft tissue injury, #, retained foreign Body or ruptured globe. Ruptured Globe – Most serious – early evaluation essential.

45. Parotid Injury UNCOMMON Need to aptly address to avoid complication Parotid Duct injury must be considered. Line between Tragus to Middle of upper lip Stenson’s Duct 7cm long Associated with buccal branch of Facial n. injury.

46. Massage and induce Salivation or Cannulate papilla in front of Second Molar Sialography +/- CT is Highly Sensitive consensus in the literature that acute parotid injuries should be explored primarily and the injured structures repaired, if possible

47. Facial Nerve Injury Facial nerve Injury revealed from impairement of its physiologic functions : lacrimation, salivation, and eye closure. MRI with gadolinium enhancement for soft tissues CT is ideal for assessing bony structures Asso . with temporal bone fractures (more with Transverse than Longitudinal #) Longitudinal is MC 80% Temporal bone fracture. GSW/ Penetrating are other causes

48. Corticosteroids are commonly used as primary therapy or an adjunct to surgical intervention nerve repair should be followed, including performance of direct end-to-end nerve anastomosis (for transected nerves) or interpositional nerve grafting, whichever can offer tension-free secure connection. Interposition grafts or cable grafts -with the sural nerve or greater auricular, or hypoglossal-facial nerve anastomosis

49. Trigeminal nerve Injury Signs and symptoms are highly dependent branches affected. V1, V2, and V3 and their specific branches present chronic and burning pain to paresthesias and difficulty chewing inferior alveolar and lingual nerves are the most commonly injured peripheral branches of the trigeminal nerve. Infraorbital nerve is also susceptible to injury

50. MRI Imaging of Choice . Timing of surgery varies by cause Immediate repair, if Possible OR Delayed reconstruction, in gross wound contamination, and large soft tissue defects. Delayed repairs within 1 week, or when early secondary repair has started (granulation tissue formation, etc.), also have excellent prognosis for recovery of sensation

51. Dento Alveolar injury Tooth injuries Luxation Complete Partial 2. Subluxation 3. Fracture

52. Dento alveolar fracture Any portion of alveolar process involved. Maligned and displaced teeth. Cl/f Soft tissue laceration Damage to teeth Alveolar fracture

53. Management Dentoalveolar fracture requires early reduction and stabilisation or immobilisation by splinting to adjacent stable teeth. The wiring techniques are simple and rapid immobilisation of the alveolar segments utilising the teeth for support is possible: 1. Direct interdental wiring 2. Continuous or multiple loop wiring 3. Arch bars— Stabilisation with arch bars give the best form of immobilisation , though sometimes a simple resin composite splint may also help

54. Dental wiring techniques

55. Route of feeding after faciomaxillary trauma and postoperatively Oro and naso gastric feeding Cervical pharyngostomy Alternative feeding method for patients with severe facial trauma Advantage –nasal and oral cavity can be kept clear of tubes

56. THANK YOU