Maxillofacial Trauma

Anthony G. Hillier, D.O.

St. John West Shore
Emergency Medicine Resident

Etiology and Incidence

Multisystem

injury 20-50%
Nasal and mandibular fractures most
common in community EDs
Midface and zygomatic injuries most
common in Trauma centers
25% of women with facial trauma result of
domestic violence
Incidence of concomitant cervical spine
injuries with facial fractures

Etiology and Incidence

Older

age, MVC and TBI-higher incidence

Facial

fractures-a distracting injury?

Carotid

artery injury

Blindness

may occur with facial fractures

Maxillofacial Trauma

Emergency Management and

Resuscitation
Airway

Most urgent complication-Airway compromise

Simple interventions first
No mandible?
Intubation

Avoid nasotracheal intubation

May not want RSI
Benzodiazepines
Ketamine
Etomidate

Be Prepared and Be Creative

Emergency Management and

Resuscitation
Airway

Management Options

Awake intubation
Laryngeal Mask Airway
Fiberoptic intubation
Lateral or semi-prone position
Percutaneous transtracheal jet ventilation
Retrograde intubation
Cricothyroidotomy

Emergency Management and

Resuscitation
Hemorrhage

Control

Rarely develop shock from facial bleeding alone

Direct Pressure
LeFort Fractures
Nasal hemorrhage may require A&P packing

History

Vision
Teeth alignment
Abuse

Maxillofacial Trauma-Physical Exam

Inspection

Facial elongation
High

grade LeFort Fracture

Asymmetry
Deformities

and cranial nerve injury

Palpation

Tenderness
Step offs
Facial stability

Crepitus
Subcutaneous air
Cutaneous anesthesia

Maxillofacial Trauma-Physical Exam

Periorbital

Exam

and Orbital

Perform early

Professional Lid
Retractor

Maxillofacial Trauma-Physical Exam

Periorbital

and Orbital Exam

Look for exophthalmos or enophthalmos

Pupil shape
Hyphema
Visual acuity
Entrapment signs
Raccoon sign

Bimanual

Palpation Test

Maxillofacial Trauma-Physical Exam

Penetrating

Injuries

Occult globe penetration

Eyelid lacerations
Nose

Septal hematoma
CSF Rhinorrhea
Ears

Subperichondral hematoma
Hemotympanum
Battle sign

Maxillofacial Trauma-Physical Exam

Oral

and Mandibular Exam

Mandible deviation
Teeth malocclusion
Paresthesia
Tongue Blade Test
95%

Sensitive
65% Specific

Maxillofacial Trauma-Imaging
Head,

chest and abdominal trauma takes

precedence
PE detects up to 90% of fractures
Plain Films
CT
Orbital fractures
3D images available

Maxillofacial Trauma-Specific
Fractures
Frontal

Sinus/Bone Fractures

Direct blow
Frequent intracranial injuries
Mucopyoceles
Consult with NS for treatment, disposition and
antibiotics

Nasoethmoidal-Orbital

Injuries

Lacrimal apparatus disruption

Bimanual palpation if medial canthus pain
CT face

Maxillofacial Trauma-Specific
Fractures
Orbital

Fractures

Usually through floor

or medial wall
Enophthalmos
Anesthesia
Diplopia
Infraorbital stepoff
deformity
Subcutaneous
emphysema

Maxillofacial Trauma-Specific
Fractures

Orbital Fissure Syndrome

Fracture of the orbital canal

Extraocular motor palsies and blindness

If significant retrobulbar hemorrhage, may need
cantholysis to save vision

Zygomatic Fractures
Tripod fracture

Arch fracture
Most

common
Most serious
Outpatient repair
Lateral subconjunctival hemorrhage
Need ORIF

Tripod Fracture

Maxillofacial Trauma-Specific
Fractures
Maxillary

Fractures

High-energy injury
100x gravity
Malocclusion
Facial lengthening
CSF rhinorrhea
Periorbital ecchymosis

LeFort Fractures

Maxillofacial Trauma-Specific Facial

Fractures
Mandibular

Fractures

Second most common facial fracture

Plain films
Often multiple
Panorex
Malocclusion
CT
Intraoral lacerations
Sublingual ecchymosis
Open Fractures
Nerve injury
Pen

G or Cleocin

Body

30-40 %

Angle

25-30 %

Condyle

15-17 %

Symphysis

7-15 %

Ramus

3-9 %

Alveolar

2-4 %

Coronoid Process

1-2 %

Questions?
Thank You!

Lecture Questions
1.

What portion of the mandible is most

commonly fractured?
a.
b.
c.
d.
e.

Ramus
Coronoid process
Body
Angle
Symphysis

2.

Orbital fractures can cause all of the

following except:
a.
b.
c.
d.
e.

Blindness
Motor palsies
Facial anesthesia
Enophthalmos
Hyphema

3.

Which of the following is/are true

regarding maxillary fractures?
a.
b.
c.
d.
e.

Only minimal force necessary

Rarely cause CSF rhinorrhea
May cause facial lengthening
Usually the only sustained injury
All of the above are true

4.

The best modality for diagnosing an orbital

or facial fractures is
a.
b.
c.
d.
e.

Plain films
MRI
CT
Ultrasound
Osteopathic palpation

5.

Which statement below is correct?

a. Midface fractures usually have minimal
morbidity
b. The tongue blade test is quite sensitive in
assessing need for mandibular xrays
c. The bimanual nasal exam is crucial in possible
medial orbital wall fracture
d. Midface fracture is an indication for
nasotracheal intubation and RSI is often
needed in these patients
c, e, c, c, b