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Mark Wells, MD, FRCS (C), FACS: Assistant Clinical Professor of Plastic Surgery Grant Medical Center Columbus, OH
Mark Wells, MD, FRCS (C), FACS: Assistant Clinical Professor of Plastic Surgery Grant Medical Center Columbus, OH
Panfacial Fractures
Management of facial fractures has historically been broken down into thirds
Upper Third
Frontal bone Supraorbital rim
Middle Third
Zygoma Nasal bone Maxilla
Lower Third
Mandible
Panfacial Fractures
Often involve high velocity injury Associated with other polytrauma Facial fracture treatment is not generally the priority
Panfacial Fracture
Definitive care of the maxillofacial injury should only be rendered after a thorough multisystem evaluation
Airway Blood Loss Central Nervous System Injury
Brain C-spine
Panfacial Fractures
Concentrate on the ABC's during the resuscitation Do not allow the facial injury to distract your from the priorities
Brain Injury
CT scan of the brain, face, skull and neck should be completed on all facial trauma patients The presence of coma should not preclude the treatment of associated facial injuries once the patient is stable
Panfacial Injuries
Indications for immediate operative intervention
Airway Bleeding Compound Injuries
Airway
Early concerns
Securing and adequate airway in the face of unstable fractures, bleeding and soft tissue injury
Late concerns
Surgical access for repair during general anesthesia
Airway
Clear oral cavity of debris, blood, teeth and clot Loss of support of the base of the tongue can cause airway obstruction Traction on the mandible and tongue can avert asphyxiation
Airway
Endotracheal intubation with C-spine control is the most expeditious method to secure and airway in an acutely compromised airway
Oral Nasal
Airway
In extremely urgent situations where oral or nasal intubation is not possible emergency cricothyroidotomy is indicated
Airway
Cricothyroidotomy is converted in the operating room to formal tracheotomy
Facilitates placement of the patient into intermaxillary fixation Makes pulmonary management easier Minimizes inadvertent extubation in a swollen patient
Profuse Bleeding
Superficial bleeding can often be controlled by packing or temporarily closing open wounds over fractures
Profuse Bleeding
Treatment of closed hemorrhage is often more difficult
Anterior and posterior nasal packing Reduction of displaced fracture fragments
Profuse Bleeding
Selective arterial embolization of branches of the external carotid artery Profuse bleeding from the carotid artery and dural venous sinuses at the base of the skull is difficult and often fatal Selective arterial ligation of both external carotids and superficial temporal arteries is a last resort
Physical Examination
Careful history and thorough clinical examinations form the basis of the diagnosis Orderly examination from superior to inferior aspect of the craniofacial skeleton
Physical Examination
Bilateral orbital ecchymosis Lengthening of the face Mobility Intraoral step off Malocclusion Panda face
Physical Examination
Loss of nasal projection Telecanthus Enophthalmos Entrapment
Radiographic Evaluations
CT scan With 3-D Reconstruction
Brain, Face and Neck
Radiographic Evaluation
Plain films
Difficult to evaluate Require multiple views Require a larger radiation dose Generally not cost effective
Radiographic Evaluation
Panorex
Not readily available in most hospitals Critically ill patients cannot sit in the panorex machine to have the film completed Has been largely supplemented by CT scanning
Radiographic Evaluation
3 D CT scan of facial bone
Can be quickly and economically generated Superior to multiplanar 2D images in demonstrating the spatial relationships between the bone fragments in complex facial trauma
Goals of Treatment
Restore function Maintain facial aesthetics Earlier treatment generally results in superior results
Soft tissue contracture is minimized Infection rates are decreased
Miniplate Stability
Decreased the incidence of infection Decreased the need for tracheotomy Earlier release of IMF
Intermaxillary Fixation
Important to establish IMF prior to plating fractures Only a small error in plate fixation can result in significant malocclusion With rigid fixation, IMF can often be released at the end of the case
Access Incisions
Depend on the underlying fracture pattern In panfacial injuries, rarely can wide exposure be performed through overlying lacerations
Summary
Facial injury remains one of the most common injuries presenting to regional trauma units Recognition of associated life threatening conditions is key to preventing loss of life or further morbidity Early treatment with modern craniofacial techniques speeds recovery and prevents secondary deformity