EPIDEMIOLOGY:

_ million facial fractures per year due to MVC/MCC

__% have multi-system traumatic injuries

___-___% have assocaited TBI

 ___-___% have concomittant C-spine injury

__% develop blindness or visual impairment

3 million facial fractures per year due to MVC/MCC

60% have multi-system traumatic injuries

20-50% have assocaited TBI

 .3-4%  have concomittant C-spine injury

.5-3% develop blindness or visual impairment

MVC

interpersonal violence

motor cycle collision

sports

falls

industrial accidents

bites

penetrating (aka knife and gun club)

airway obstruction

hemorrhage

Err on the side of early intubation

chin lift

jaw thrust

oropharyngeal suction

lateral/semi-prone

finger-sweep

Intubation:

When do you intubate? What shoudl GCS  be?

What are your options for intubation?

GCS less than or equal to 8 (nl=15)

massive soft tissue damage

airway at risk

Options:

Awake intubation(ETT)

Laryngeal maask airway

fiberoptic intubation

RSI ETT

Last resort= cricothyroidectomy

MOI

LOC

amnesia

discharge

vision changes

pain with eye movement

facial numbness

mouth pain

malocclusion

AMPLE: allergies, meds, PMH, last meal

Tetatnus, events leading to injury

How do you assess facial injuries?

Clinical Exam

Inspect soft tissue

lacerations, edema, ecchymosis, bleeding, CSF leak, epistaxis, septal hematoma

Dental

Malocclusion, intra-oral laceration, dental fractures, tooth-avulsion= r/o aspiration

Palpate entire skull and facial bones

Tenderness

Deformity

Crepitus

Mid-Face Mobility

Step-Off

Trismus

Visual acuity

EOM entrapment

pupil shape, location, reactive

foreign body

subconjunctival hemorrhage

orbital ecchymosis

enopthalmus- "sunken" eye

exopthalmus- proptosis/bulging eye

How do you know you have a globe injury? 8

F<T< S<F<A<D<P<H

fat protruding from globe

peaked tear-drop pupil

severe conjunctival hemorrhage

full thickness cornea or sclera laceration

absent red reflex

dislocated lens

prolapsed iris

hyphema

raise eyebrows

close eyes

frown

smile

puff cheeks

V1: opthalmic

V2: maxillary

V3: mandibular

Plain films: CSR, Pelvis, Extremities

Water's, Townes, Caldwell, Mandible Series (types of views

Panorex

CT Scans: head, C-spine, chest, abdomen/pelvis

CT facial bones: coronal/axial and 3 D reconstruction

What is the most common facial fracture?

What are possible etiologies?

nasal fracture

etiologies: assaults, sports injury

MVC: airbag

linear

depressed

comminuted

Pt presents with periorbital ecchymosis

nasal deformity present

edema

epistaxis (r/o septal hematoma)

What could it be?

what x-rays?

Nasal fracture

x-rays: nasal bone series

no nose blowing

upright position

ice packs

analgesia

packing for epistaxis

ENT 24-48 hrs

**must differentiate from NOE fracture

Pt presents with pain on eye movement.

you note a flattened nasal bridge, saddle nose deformity, traumatic telecanthus.

You note CSF rhinorrhea.

Imaging: CT facial bones (coronal/axial/3D)

OMFS consult

ABX: sinus flora

Surgery

An orbital floor fracture:

What does it typically involve?

MOST COMMON MID-FACE FRACTURE

involves orbit floor

involves medial wall orbit

Patient presents with diplopia upward gaze, periorbital ecchymosis, exopthalmus, enopthalmus, entrapped EOM, step-off, infra-orbital hypoesthesia.

What could it be?

What type of radiographs do you order for orbital floor fracture? what view?

what type of sign will you see?

what will radiographs show?

plain film: water's view

coronal CT scan

hanging tear drop sign

open "bomb bay" door

show: air/fluid level maxillary sinus

orbital emphysema

OMFS consult

Optho consult

Decongestants

NO NOSE BLOWING!!

Abx: PCN/1st gen cephalosporin/Clina

Surgery

Mandible:

what is the most common part of the mandible to fracture?

__% bilateral

How are the fractures classified?

Pt presents with pain, bit-off center, malocclusion, swelling, intra-oral lacteration (separated teeth), sub-ungal hematoma, trismus, V3 hypoesthesia/

WHat could it be?

Panorex: GOLDEN STANDARD

Mandible series

Towne's View

CT scan

What's the treatment for mandible fracture?

Non displaced vs open/displaced

Non displaced:

Analgesia

Soft diet or full liquids

Peridex mouth rinse

Barton's bandage

OMFS: 24-48 hrs.

Open/Displaced:

Urgent OMFS

Antibiotics

Surgery

Pt presents with malocclusion anterior open bite, facial edema, crepitus, pain with clenching, and motion of maxilla (put thumb on hard palate and able to move back and forth.)

What is this?

What type of imaging do you want for Lefort I fracture?

What's treatment?

CT facial bones: axial/coronoal; 3D recon

Treatment: OMFS, ABX, surgery

Pt presents with malocclusion, marked facial edema, infraorbital ecchymosis, nasal bridge flattening, traumatic telecanthus, midface mobility, diplopia/EOM entrapment, V2 paresthesia, epistaxis/CSF rhinorrhea.

What could it be?

pyramidal fracture

fracture though the nasoethmoid complex

Lefore II fracture:

may be associated with what other kind of fracture?

What is the imaging and treatment?

may be associated with what other kind of fracture?

NOE

Imaging: CT-facial bones

T//C CT angio neck

Treatment:

Ice/HOB elevation

Decongestants

Steroids-per Surgeon

OMFS: Optho eval

Surgery

Pt presents with signs of malocclusion.

Airway compromise, disface deformity, "raccoon eyes," enopthalmus, epistaxis, CSF rhinorrhea, significant mid-face mobility, NOE fracture findings.

What type of imaging do you want for Lefort III fracture?

What treatment?

Imaging: ONLY FACIAL BONES (axial/coronal/3D)

Consider CT angio neck

Treatment:

early intubation, ABX, OMFS- optho eval

surgery

Head of bed: elevated to thirty degrees

zygotmaticmaxilary complex fracture

MOI: direct blow: high impact

assoc with eye injury

isolated arch fracture: most common

frontozygomatic suture

zygomatic arch

inferior orbita rim

orbital floor

anterior/lateral wall maxilla

ZMC clinical findings

TIDES mneumonic

Trismus

Infra-orbital hypoesthesia (V2)

Diplopia

Epistaxis

Lack of Symmetry- flattened cheek

Pt presents with periorbital ecchymosis, pain, "flame sign (subjunctival hematoma lateral from lid), binocular diplopia, SQ air cheek, misalignment pupils.

What could it be?

What type of imaging do you want for ZMC fracture?

What type of treatment?

Surgery needed?

Imaging: 

Water's

Submental "bucket handle view" (chin up)

CT facial bones gold standard

-air fluid levels maxillary sinus

soft tissue emphysema

displaced bony fragments

Surgery: 10-15% will NOT need surgery

Treatment:

analgesia/ICE

No nose blowing/decongestants

ABX for open fracture

OMFS consult

Pt presents with cranial nerve and LOC crucial

Costmetic deformity

laceration

crepitus

CSF rhinorrhea

tenderness

periorbital ecchymosis

What could it be?

What type of imaging do you want with frontal sinus fracture?

What treatment?

Surgery?

Imaging:

coronal/axial CT facial bones

Treatment:

admission, OMFS consult, ABX: augmentin/Unasyn

Surgery:

Ant Table: no OR unless consmetic defect

Posterior table: ORIF +/- obliteration of sinus

Labs:

Ring/Halo test

Glucose CSF drainage (≥45)

Beta 2 Transferrin

Imaging:

Ct facial bones

Treatment:

Bedrest, flat, IV abx, neurosurgery, lumbar drain

local trauma

iatrogenic

topical nasal drugs

oral anticoag: ASA, Coumadin, Plavix

nasal septum- most common

Kiesselbach Plexus: where 4 arteries anastomose 

• anterior ethmoid artery
• great palatine artery
• sphenopalatine artery
• superior labial artery

posterior balloon

epistakxis both naries

blood dripping posterior naso-pharynx

Pt prsents with mobility of segment of teeth.

What could it be?

What's treatment?

alveolar fracture- bone supporting teeth

Tx: reduction and fixation

What's diagnosis?

missing tooth with "fresh" socket

what's treatment?

tooth avulsion

tx: <1 hr irrigate tooth with NS, replace in socket. Refer to dentist

>1 hr=lost tooth

I: thru enamel only

smooth rough corners dental drill/emory board

IIthru enamel and dentin

cover with zinc oxide or calcium hydrooxide paste (Dycal)

Tx: Refer to dentist, pain meds, abx

Facial lacerations: KEY POINTS

Rapid within __ hours

Facial nerve transection: repair within __ hrs.

T/C ____

Assess ___ nerve before infiltrating local

large, complex lacerations: __ REPAIR

What is the goal?

Facial lacerations: KEY POINTS

Rapid within 24 hours

Facial nerve transection: repair withinc 72 hrs.

T/C parotid gland injury

Assess facial nerve before infiltrating local

large, complex lacerations: OR REPAIR

What is the goal? Irrigation, Debridement, Layered Closure, Tension-free skin closures, sharp clean margins

Eye brow laceration:

What do you NOT do?

What type of suture?

ROS _ days

Do NOT shave

Non-absorbale 5-0 or 6-)

ROS 5 days

Eyelid laceration:

what type of suture?

lid margin and or/tarsal plate: optho or plastics

6-0 absorbable suture

Nose laceration:

what type of suture?

ROS?

Superficial: 5-0 or 6-0 non absorbable suture

Complex: key sutures first at distinct nasal landmarks

ROS 3-5 days

Ear laceration:

what type of suture?

ROS?

simple linear: 5-0 non absorbable

Cartilate involved: t/c OMFS or Plastics

(RISK: perichondral hematoma "cauliflower ear")

ROS 3-5 days

Rules of thumb for Lip lacerations:

what do you do before injecting local?

what do you consider about vermillion border?

through and through lacerations?

align, mark landmarks prior to injecting local

the vermillion border should be carefully aligned and the lip and skin is closed with 5.0 or 6.0 nylon

ROS 3-5days

For througha nd through lacerations the oral mucosal surface is closed first with a sbsorbale suture material- Vicryl or Chrmic Gut

Deep sutures may be required to eliminate dead space

How do you do a tongue laceration?

what suture?

soak gauze with topical lidocaine in laceration x 5 mins before local

absorbale suture

ABX

>30% defect consult OMFS or Plastics

COPIOUS IRRIGATION

remove crushed tissue

leave puncture wounds open unless deep

close loosely 5-0 non-absorbale

update tetanus

Abx: augmentin drug of choice

ROS 3-5 days

• max bonding strength in 150 seconds
• equiv strength in 7 days
• topical anesthetic only
• better accepted by some pts (children)
• sloughs off naturally
• no return for suture removal

what is dermabond?

it is an alternative to what?

use?

Contraindications?