MEMENTO MORI

MAXILLO-FACIAL TRAUMA

R.Drummond
October 24, 2002
preceptor: Carol Holmen

Overview

General approach to facial trauma

Epidemiology
anatomy
diagnostic imaging
specific conditions
diagnosis of facial trauma as a
presentation of abuse
Conclusions

General Comments

Injuries to the face devastating to patient

physical, emotional, occupational, sequelae
Two presentations simple, isolated injuries clinically
stable vs. Manifestation of severe
trauma
25% of maxillofacial trauma involves litigation
most injuries can be picked up on thorough clinical
assessment
Our role is usually to diagnose not treat
Overlap of specialists ENT, OPHTH,PLASICS,
NEUROSURGERY, DENTISTRY

Question 1: The single most valuable xray of the

mid-face is:

1)Waters view
2)Lateral view
3)Caldwell view
4)Townes view

Question2 : Most associated injuries in cases of

maxillofacial trauma are to the:

1)brain
2)cervical spine
3)chest
4)abdomen

Question 3: Open bite may be secondary to all

except:

1)LeFort Fracture
2)tripod fracture
3)mandibular fracture
4)NEO fracture

Question 4: All of the following are true about

children with maxillo facial trauma except

1)greater risk of lower cervical

spine injury
2)intracrainial injury is higher
3)mid-face fracture higher as child
grows
4)non-accidental trauma should be
considered

Triage scenario

Two vehicle head on collision, driver and

front seat passenger in one vehicle,
single driver in second vehicle
cars each going 30 m.p.h.
all were unrestrained
all brought to ED by EMS
all on spinal boards

Patient 1

5 year old child passenger of car

windshield fractured in target pattern
No LOC
Large Laceration across forehead , boggy
swelling of skin, moderate watery epistaxis
HR 140 BP 90/45 RR 34 (crying) sats 100%
GCS 15

Patient 2

26 year old woman, was driver of the car

face hit steering wheel... No L.O.C.
Badly injured face, no other obvious injuries
gasping I have to sit up I cant breathe
vitals HR 120 BP 90 /40 RR 36 Sats 89 on
10litres GCS 14
primary survey gurgling resps with considerable
blood in mouth gaping wounds across forehead
jaw is mangled with evident deformity

Patient 3

18 year old driver of other vehicle works

as a miniaturist painter, lost his bottlebottom spectacles at scene of accident
hit drivers side window
No L.O.C.
HR 100, BP 120/75 RR 24 sats 98%
GCS 15
badly lacerated L face with deformity
tender over zygoma diplopia numbness
over cheek positive Marcus Gunn

Force of Gravity Necessary to Injure Face

Nasal Bones 30 x gravity

Zygoma 50 x gravity
Angle of Mandible 70 x gravity
Frontal Globellar region 80 x gravity
Midline Maxilla 100 x gravity
Supraorbital rim 200 x gravity

Basic Epidemiology

Most common causes:

MVAs, falls, assault
community: nose and mandible

urban:

:MVAs and Sports

midface, zygoma
penetrating and assault

more than 60% have associated

other injuries

MVA

Epidemiology of MaxilloFacial Injuries at Trauma

Hospitals in Ontario, Canada between 1992 and
1997
The Journal Of Trauma, September 2000... Hogg et al

Ontario Trauma Registry new database

15 -22 % of trauma patients severe maxillofacial
injuries
2,969 patients in 12 trauma centers
male: female 3:1
most common cause mvas
26% positive BAC
understanding causes severity temporal
distribution effective treatment and prevention

ASSOCIATED INJURIES

TYPE OF FRACTURES

MONTH

TIME OF DAY

AGE AND GENDER

Long Term Physical Impairment and Functional Outcomes

after Complex Facial Fractures
Plastic and Reconstructive Surgery, August 2001 Girotto,
MacKenzie et al

Retrospective cohort study of adults 18 - 25

265 pts with LeFort fractures compared to 242
pts with severe general injury
followed with several tools to assess health and
well being
(General Health Questionnaire, Body Satisfaction
Scale, Social Avoidance and Distress Scale)
hypothesis early intervention at tertiary care
trauma center better results
complex facial fractures represent subset of
trauma with more longterm complications

Obvious sequelae:
Diplopia 56% Zygomatic fractures
23% LeFort fractures
20 -31% midface fractures difficulties mastication
35% Anasomia in LeFort Fractures
Epiphora midface fractures 25- 45 %
facial numbness 32 -35 %

55% of facial fractures returned to work at one year

compared to 70% less severe facial fractures other
general injuries

An appreciation of the long term physical and

psychological sequelae of injury is essential for
evaluating current treatment plans and to assist
in providing appropriate counseling or referral
to other healthcare professionals

Triage and immediate management

Airway management first and major priority

be prepared for surgical airway
clear cervical spine then let patient adopt most
comfortable position
caution re nasal tracheal intubation
if RSI prep for cricothyroidectomy
awake intubation
ketamine a good drug
tongue often obstructs

Shock and Hemorrhage

Maxillofacial Trauma seldom cause of shock

60% association other injuries
If shock check for other sources
with severe facial smashes
reduce fracture plates
severe epistaxis hard to control : Foley

All patients with significant facial injuries

must be presumed to have cervical spine
injury until proved otherwise

History

Mechanism of injury
blunt vs. Penetrating
L.O.C.?
questions:
Do you see double?
Are there areas of numbness on your face?
Does your bite feel normal?
Which areas on your face hurt?
Does it hurt when you open your mouth and
where?
Consider abuse

Physical Exam

Inside Out and bottom up

birds eye view and worms eye view
Gestalt
90% of all facial fractures can be picked up or
suspected by careful palpation
careful ocular exam visual acuity fields
subconjunctival hemorrhage
Pinpoint exam, Marcus Gunn exam
raccoon eyes, battle sign
halo test
intranasal palpation test

Allergies
Tetanus status

Anatomy

Vertical buttresses: nasal, frontal, and zygomatic

maxillary give vertical stability
zygomatic temporal buttresses horizontal support

Three Zones of Facial Anatomy

UPPER: Superior Orbit and above Frontal Bone

MIDDLE: Superior Orbital rim to occlusal surface
Orbits, Nasal bones, Zygoma, Maxilla
LOWER: mandible, teeth

clinical exam should guide and direct radiological

exam

FACIAL BONES

NERVES OF FACE

Diagnostic Imaging

Standard Four Views

Waters
Caldwell
Lateral
Submentovertex
Occlusal views
Panorex

Waters View

Most valuable
prone.... Clear c-spine
draw four lines should be parallel and smooth

WATERS VIEW

WATERS VIEW

WATERS VIEW PARALLEL LINES

Caldwell View

Supplements Waters view

superior orbital rim
sinuses
orbital region
can see teardrop sign
open bomb bay door sign

CALDWELL VIEW

CALDWELL VIEW

Lateral View

Frontal Sinus
maxillary sinus
occasionally pterygoid plate

LATERAL VIEW

Submentovertex view

Jughandle view
Main value is to see zygomatic arch

SMV VIEW

X-rays good screening test to guide which CT

scan to order and level
Ctscan most useful to grade injury and plan
surgery
most useful for orbital and maxillary fractures
blowout fractures in particular
axial and coronal
can do 3-D reconstruction

Lefort III

DENTAL PANOREX

PEDIATRIC DENTAL PANOREX

18 year old girl playing catcher at slo-pitch

baseball game hit in forehead by baseball bat
large laceration with swelling forehead 3 min
LOC

What to look for on exam??

Crepitation, subcutaneous emphysema, soft
doughy feel
check laceration carefully
check for csf in nose halo sign

Frontal Bone Injuries - Anatomy

Proximity to brain, nose, orbits

outer table thicker than inner
dura forms inner periosteum
intracranial injuries esp if posterior wall
one study 89% significant frontal bone fractures
eye problems including blindness

FRONTAL BONE

FRONTAL BONE

FRONTAL BONE #

FRONTAL BONE #

FRONTAL BONE #

Investigations

Skull films useful

if xray positive Ctscan

Management

CNS or ENT consult

??Antibiotics

if yes, first generation cephalosporin

clavulin or septra
anterior wall elevation for cosmesis

32 year old male partying at Dutch Creek

campground pitched tent on sixty foot cliff drank
twelve beer and smoked two joints got up at 4 am
to take a leak... He hit the bottom before his pee.
Four hour rescue operation in the dark. After trip
to local hospital full work up showed only large
ecchymosis and swelling over base of nose
noted to have continuous tearing left eye double
vision

NASO-ORBITAL-ETHMOIDAL (NOE or NEO)

FRACTURE
Zone between cranial, orbital, and nasal cavities
disorganization of skeletal structure
check intercanthal distance.... Telecanthus
intranasal palpation test
CSF rhinorrhea
septal hematoma
fine cut Ctscan coronal sections

Nasal Bone Fractures

Three questions
Have you ever broken your nose before?
How does your nose look to you?
How is your breathing?

# NASAL BONES

NASAL BONE #

Findings

Crepitus, hypermotility, edema, tenderness, deformity

depressed vs. Laterally angulated vs comminuted
if mechanism severe look for other injuries
control epistaxis
look for septal hematoma..... Drain
are xrays necessary
if early: reduce with simple pressure
if late: needs operative repair
f/u with plastics more important than x-ray

Pediatric Concerns

Bones not fused

can develope growth retardation
if significant needs complete reduction
f/u plastics in 4 days

28 year old bungee cord jumper in Australia

jumping off bridge in the dark 100 feet hit surface
of water went three feet under water... Ok that
night next day very swollen face double vision on
exam could not get left eye to look upward

BUNGEE CORD JUMPER

BUNGEE JUMPER BLOWOUT

ORBITAL BONES - what is bone 3 called??

BONES OF THE ORBIT

ORBIT: ANATOMY

ORBIT: ANATOMY

Orbital Fractures

After life-saving measures preservation of

eyesight next main priority
blunt trauma to orbit or globe
seven bones in orbit any guesses?
frontal, zygoma,sphenoid, ethmoid, maxilla,
palatine.....and
lacrimal
cone or pyramid in shape
design feature

BLOWOUT LEFT EYE ENTRAPMENT

EOM ENTRAPMENT IN BLOWOUT

BLOW OUT TEARDROP SIGN

ORBITAL BLOWOUT

BLOW OUT AIR FLUID LEVELS

Dangerous triad decreased field,double vision,

decreased visual acuity
distinguish pure from impure orbital fractures
pure orbital fracture synonymous with Blow Out
first called this by Smith and Regan 1957
first described in 1844

Ask:
Do you have double vision?
Do you have numbness cheek, lip, mandibular teeth
often examiner neglects superior and lateral rim of
orbit
subcutaneous emphysema pathognomonic for rupture
into maxillary sinus

PERIORBITAL EMPHYSEMA

Diplopia

Complicated by edema, blood, temporary

neuromuscular injury,change in orbital shape,
third nerve palsy
entrapped EOM does not resolve
forced duction test
Enophthalmosis :retraction of eye into socket

investigations

Xray finding Caldwell

teardrop sign
open bomb bay door sign
air/fluid level in maxillary sinus
CT scan definitive

BLOWOUT

MEDIAL WALL BLOWOUT

CORONAL SLICES THROUGH ORBIT

BLOWOUT FRACTURE

Management

Any questionable midface injury consult

ophthalmologist
many delay repair for two weeks
AB if subcutaneous emphysema
do not blow nose
rare malignant periorbital emphysema
lateral canthotomy

The Diagnosis and Management of Orbital Blowout

Fractures Update 2001
Brady, McMann et al., American Journal of Emergency Medicine

100 Blowout Fractures

59 pure blowout fractures
age 8 to 75
falls, aggression, and sports
periorbital ecchymoses, diplopia, hypoesthesia in
V2 intraorbital emphysema
plain xrays 13/26 false negative
only 5 true positives
CT 51/59 true positives

Implants 35/55 cases

lyophilized bovine before 1996
controversy in 1971 and 1974
most enophthalmosis and diplopia spontaneously resolve
orbital floor repair dangerous

current recommendations:
surgery if diplopia from entrapment not gone 2 weeks
enophthalmosis greater than 2 mm
orbital floor greater than 50% blown out
(unacceptable cosmetic results)

Do not recommend plain xrays

direct Ctscan
cold packs x 48 hours
use of nasal decongestant
no ASA
no nose-blowing
Steroids
broad spectrum antibiotics
transconjunctival approach

56 year old male street person drank a little too much

MogenDavid kicked in face as he slept on heating grate
swollen left face subconjunctival hemorrhage lateral
deviation of eye

ZYGOMA FRACTURE

ZYGOMA TRIPOD #

ZYGOMA TRIPOD #

ZYGOMA TRIPOD FRACTURE

TRIPOD FRACTURE

ZYGOMA ARCH FRACTURE

ZYGOMA ARCH #

3D RECONSTRUCTION # ZYGOMATIC ARCH

Cause

Second most common facial fracture after nasal

bones
tripod vs arch
articulates with maxilla, frontal and temporal
bones
tripod more serious
arch more common

What Questions to ask

Does it hurt to open your mouth?

Is your lower lid, cheek, teeth numb?

MASSETER MUSCLE

Findings

Masseter attachment
pulls bone lateral and inferior
vertical dystopia
ipsilateral epistaxis
edema masks deformity
check for symmetry
check inside of mouth for tenderness zygomatic
arch

Investigations

Single Waters view

submentovertex view
Ctscan definitive

Management

Rule out ocular injury

admit tripod fracture
OPD for arch fractures f/u for plastics
elevated with Gilles elevation

44 year old thrown off motorcycle ruptured

spleen required 14 units PRBCs third day in ICU
on ventilator noted to have badly swollen
ecchymotic skin around face with unusual
distortion (according to sister) massive bruising
around eyes

Maxillary Fractures

Huge amounts of energy

high association with other injuries
classification system
LeFort I,II, III IV
usually seen in textbooks
in practice combinations of the above
can be greenstick or impacted
they all involve malocclusion

MAXILLARY FRACTURE

LEFORT I II AND III

LEFORT I

LEFORT II

LEFORT III

LEFORT II AND III

Questions if Conscious?

Does your bite feel normal?

Is your lip numb?
Does your jaw hurt? Where?
Site of premature contact points to fracture site
disruption of periosteum

Investigations

Plain films not useful

plain waters view
any haziness or any suspicion CTScan
2 - 3 mm coronal cuts
if intracranial air open skull fracture

Management

Usually given antibiotics

does not usually in itself cause airway
obstruction
sometimes needs aggressive airway
management
nasal packing can distract fracture
foley catheter with saline
pushing fracture back into place stops bleeding
LeFort II and greater ORIF

38 year old woman wont make eye contact not

forthcoming how she was hurt... Cannot open or
close mouth without severe pain swollen over
angle of left jaw

Mandibular Fractures

Fractures chin points to side of injury

dislocation chin points away from injury
located to symphysis, body angle,condyle or
subcondylar area
third most common fracture, after, nose and
zygoma
At least half of mandibular fractures multiple
second fracture often distal
open book fracture
symphysis plus bilateral condyles

MANDIBULAR FRACTURES

MANDIBULAR #

MANDIBULAR FRACTURE

COMBINATION FRACTURE MANDIBLE

FRACTURED MANDIBLE

MANDIBLE FRACTURE

MANDIBULAR FRACTURES

FRACTURED MANDIBLE AT ANGLE

Questions:

How is your bite?

Does your jaw hurt?Where?
Is your lower lip and or chin numb?

Investigations

Tongue Depressor test

plain films esp panorex usually adequate

Management

Compound Fracture by definition

needs surgery
needs antibiotics
24 g wire two teeth
Bartons bandage

# MANDIBLE REPAIRED

43 year old epileptic found post ictal (29 second

seizure) confused cannot speak properly
dysarthric mumbling cannot close mouth

Chin deviates away from dislocation

occl bilateral dislocation chin juts forward
if trauma x-ray before re-location
bartons bandage immediately
surgery if pain, spasm,, tenderness especially if
first time

TMJ DISLOCATION

Dental Avulsions

Three levels of injury to teeth

enamel, dentin (yellow) pulp
dental pulp immediate referral to dentist to avoid
abscess
if avulsed time is of essence
transport under tongue in milk or saline
gentle rinse avoid root area
works best if re located 20 mins
root does not survive greater than 2 hours
once clean replace immediately

Special considerations paediatric facial #s

Relatively rare
if injured: frontal bone not mid-face, not mandible
associated injury upper c-spine not lower
SCIWORA
worries about post injury dysplasia not
scientifically confirmed
micrognathia, asymmetry some re modelling
nasal bones a concern

More common if child less than three

nasal bone fracture common

TWO COMMON ERRORS

failure to recognize more serious facial injury
failure to recognize septal hematoma
at age twelve to fifteen sinuses pneumatize
incidence of mid-face fractures pick up
bones set quickly early f/u 4 days
any question about injury that can lead to growth
retardation early f/u

Use of Antibiotics in MaxilloFacial Fractures

Whether one should administer antibiotics for CSF

rhinorrhea and if so which one, is usually a decision made by
the neurosurgeon and usually is based on personal
preference rather than scientific data... Emergency
Medicine Clinics of North America

Practice Guidelines Vanderbilt University: Antibiotic

Prophylaxis in Cranio-Facial Trauma

ICP Monitor and ventriculostomies: Ancef 1 gm iv

prior to insertion then q8 x3 doses
CSF leak:No prophylactic AB use
Pneumocephaly: No prophylactic AB use
Open-facial fractures: Clindamycin and
gentamycin given preop and post op x 24 hours
benefits not substantiated by literature

Awareness of Maxillofacial Trauma as a

Manifestation of Abuse to Children, Women and
the Elderly

Child Abuse : The intentional physical, sexual,

or emotional mistreatment or neglect of a child
under the age of 18 by a parent, legal guardian
or caregiver that results in the injury or emotional
detriment of the child

1% of pediatric population

Age 0 -5.... 17%

6 - 14... 57%
15 -17.... 26%

75 % of fatalities happen to children under five years of age

History in family background

findings in childs behaviour

common facial fractures:

dental fractures, oral bruises, oral lacerations
mandibular or maxillary fractures
oral burns, avulsed teeth
dental x-rays multiple healed fractures

SPOUSAL ASSAULT

20% Of relationships
10 : 1 Female : Male
most injuries to face and head
30% of suicides
30% of homicides
most likely to seek help from physician
(especially emergency physician)

Lacerations head and face

hair loss, fractured teeth
fractured jaw, isolated facial fractures
bite marks, black eyes
injuries without explanation

Abuse of the Elderly

Be aware of neglect
dental caries, cheilitis poor hygiene, unkempt
appearance

perpetrator often direct care-giver

caution with hostile unconcerned caregiver

eg: inability or unwillingness to arrange
appropriate follow-up

Question 1: The single most valuable xray of the

mid-face is:

1)Waters view

Question2 : Most associated injuries in cases of

maxillofacial trauma are to the:

1)brain

Question 3: Open bite may be secondary to all

except:

4)NEO fracture

Question 4: All of the following are true about

children with maxillo facial trauma except

1)greater risk of lower cervical

spine injury

TAKE HOME POINTS

Huge amount of force to injure face: watch for other injuries

MVAs major cause of injury: strategies to prevent injuries

Major Long Term Sequelae both physical and personal

TAKE HOME POINTS

Shock is from another system usually not face

Complicated airway problems need immediate
attention
90% of fractures can be found with careful
palpation

TAKE HOME POINTS

Waters view overall most useful view mid face

Panorex most useful view for mandible

CTScan most useful modality for Orbits and

Maxilla

TAKE HOME POINTS

Frontal Bone Fracture takes lots of force check

intracranial and eye status

NOE fractures orbital fractures by definition

Nasal fractures - check for and drain septal hematomas

TAKE HOME POINTS

Orbital injury urgent referral needs Ctscan

Zygoma fractures arch common, tripod serious

LeFort fractures are rarely classic in presentation

TAKE HOME POINTS

Fractured jaw chin points to side, dislocated jaw

points away
Immediate replacement for avulsed teeth
Prophylactic antibiotics not necessary facial
fractures

TAKE HOME POINTS

Think of growth retardation in facial fractures kids

If you see facial injuries think abuse in children,
women, elderly