The integrity and appearance of face is important both socially and functionally.
CAUSE OF FACIAL FRACTURES:
Road traffic accidents
Physical violence
Sport accidents
Attempted suicide
PRIMARY CARE:
Maxillofacial injuries endanger the airway and can cause profuse haemorrhage and are often associated with neck injuries. The primary survey should be rapid and should include (ABCDE):
Airway: Evaluate & secure airway and maintain alignment of neck if there is unstable cervical spine.
Breathing: Make sure there is adequate ventilation.
Circulation: Control sources of bleeding and open IV access.
Disability: Assess level of consciousness and neurological dysfuntion.
Exposure: Ensure that all other injuries are identified.
SECONDARY SURVEY:
This is done to:
Exclude the other injuries
Categorize the extent of facial injury
Secondary survey should include:
Assessment of soft tissue injury
Proximity of injury to relevant anatomical structures like eyebrow, conjunctival margin, nasal aperture and vermillion border of lips.
Facial nerve function
Parotid duct integrity
Visual acuity, EOM, R/O retrobulbar haemorrhage and retina
Full hard- tissue examination of orbital margin, zygomatic projection, nasal skeleton and mandibular outline.
Full dental examination.
Dental occlusion and maxillary or mandibular instability is formally assessed.
MANDIBULAR FRACTURE
Often multiple and at a point of potential weakness like condylar neck, angle & parasymphysis
Parasymphysis fracture is usually due to direct violence and condylar fracture is a site of indirect violence.
SIGNS AND SYMPTOMS OF MANDIBULAR FRACTURES:
Bony step deformity
Derranged occlusion
Pain and crepitus
Sublingual haematoma
Blood stained saliva
Mobile teeth in fracture line
Anaesthesia of lower lip
Trismus
SIGNS AND SYMPTOMS OF CONDYLAR NECK FRACTURES:
Tenderness over TMJ
Trismus
Lateral open bite
Anterior open bite
MANAGEMENT
IMF is no longer acceptable practice for majority of mandibular injuries
Most fractures are treated with noncompression miniplates
The management of condylar neck fracture is controversial
Endoscopic technique may have a role in the management of certain mandibular fractures.
In Emergency room:
Place a simple wire around teeth either side of displaced fracture to reduce pain, bleeding and eased nursing care before definite treatment.
Closed reduction technique:
Limited role
Temporary IMF for more complex fractures and simple fractures can be plated.
Intact dental arch: use eyelet wires or Leonard button
Incomplete dental arch: use arch bars, intermaxillary bone pins, cast silver splint or gunning splints
External fixation:
Used for gross tissue loss or if patient is too unwell to undergo extensive surgery
Cortical screws are placed and connected with external bar of acrylic.
Internal fixation: gold standard for most displaced fracture except condylar fracture
Either an intraoral mucogingival incision or etraoral incision
For condylar fracture: use retromandibular or preauricualr incision
For ramus and subcondylar fracture: retromandibular incision.
FRACTURE OF MIDFACIAL SKELETON CAN BE SUBDIVIDED INTO:
LATERAL(ZYGOMATIC) FRACTURES.
CENTRAL( MAXILLARY, NASAL AND NAO-ORBITO-ETHMOID) FRATURES.
The classical features of midfacial fracture are:
Circum-orbital ecchymosis (panda facies)
Facial oedema
Emphysema
Lengthening of face
Anterior open bite
Epistaxis
Infraorbital sensory nerve deficit (uncommon)
Anterior open bite in Le Fort 2 and 3 fractures
Haematoma at the junction of the hard and soft palate
Floating palate and teeth in Le Fort I fractures.
Le Fort described 3 levels of midfacial fractures:
Le Fort I: This fractures runs above the floor of the nasal cavity but through nasal septom, maxillary sinuses and inferior parts of the medial and lateral pterygoid plates.
Le Fort II: This runs from the floor of maxillary sinuses superiorly to the infraorbital margin and through the zygomaticomaxillary suture. Within the orbit it passes across the lacrimal bone to the nasion. The infraorbital nerve is often damaged by involvement in this fracture.
Le Fort III: Cranio-facial dissociation
PRINCIPLES OF MANAGEMENT
Midfacial fractures compromise airway due to
torrential bleeding or epistaxis: use ANP or PNP
posterior impaction of maxilla: pull forward with middle and index finger behind the soft palate
Reduction and fixation
Fixation can be done by:
Intermaxillar fixation
External fixation
Internal suspension
Internal fixation
ZYGOMATIC COMPLEX FRACTURES
Originally termed as “Tripod fracture” because it disrupts 3 commonly recognized articulations:
Front-zygomatic
Infra-orbital rim
Zygomaticomaxillary buttress
Sometime other 2 articulations:
Zygomatic arch
Zygomaticosphenoid
CLASSIFICATION:
Fracture along vertical axis which runs between the frontozygomatic suture and the first molar tooth.
Fracture along horizontal axis in the plane of zygomatic arch
Zygomatic arch usually breaks in its weakest point , just posterior to the zygomatico-temporal suture.
SIGNS AND SYMPTOMS: Examine from front, above and behind the patient.
Face: swollen and bruised
Subconjunctival haemorrhage
Restricted eye movement: upward gaze
Blowing out of orbital content if the orbital floor is dehiscence.
Reduction of zygomatic prominence
Step deformity of infraorbital margin
Zygomatic arch may be depressed and limited mouth opening
Sensation of the cheek may be altered due to zygomaticotemporal or zygomatiobuccal nerves.
IMAGING:
Occipitomental veiw (15 and 30 degree)
USG to acess accuracy of reduction
CT scan: both coronal and axial with Hess charting if ocular motility reduced.
MANAGEMENT:
Minimally displaced: conservative
Full explanation to patient
Instruct not to blow nose for 2-3 weeks
Review in 10 days: swelling subsides
Confirm and make sure that no other intervention is required
Displaced fractures: Reduction with or without internal fixation: different methods of reduction are:
Gillies
Dingman
Poswillo hook
Keen
Coronal
POST OPERATIVE CARE:
Instruct not to blow nose for first 12 hours
Observe for s/s of retrobulbar haemorrhage which causes:
Increased pain
Proptosis
Decrease visual acuity
Diplopia
Ophthalmoplegia
Palpable increase in ocular pressure
Tense globe
Dilated pupil
Loss of direct light reflex
Management of retrobulbar haemorrhage:
Dexamethasone 4mg/kg bolus and 2 mg/kg six hourly
Acetazolamide 500 mg IV
Mannitol 20%~ 200 ml
Finally, remove the sutures and consider surgical decompression by lateral canthotomy.
ORBITAL FLOOR FRACTURE
Results from blunt trauma to the globe or adjacent bone
SIGNS AND SYMPTOMS:
Enophthalmos
Hypoglobus (depressed pupillary level)
Supratarsal hollowing
Hooding of the eyes
Narrowing of the palpebral fisure width
Infraorbital nerve deficit
Trap door phenomenon results froma small fracture of orbital floor.
IMAGING:
CT scan
USG
MANAGEMENT:
Significant orbital floor injury requires exploration and repair with grafts and materials like silastic and polydimethysiloxane (PDS)
Larger blow-out fractures repaired with iliac crest, rib or calvarium
Endoscopic transnasal approach mainly useful for repair and diagnostic purpose.
NASO-ORBITO-ETHMOID COMPLEX FRACTURES
Markowitz classification
Type I: Single large central fragment bearing canthal ligament
Type II: Fragmentation of central fragment with medical canthal ligament attached to bone
Type III: Communition of central fragment withno bone attached to canthal ligaments
SIGNS AND SYMPTOMS
Loss of nasal projection
Tipping up of the end of nose
Splaying of the nasal root
Telecanthus
Blunting of the canthal angle
MANAGEMENT:
Type I: stabilized using miniplates
Type II and III: repaired using miniplates + transnasal canthopexy
Protection