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 Crepitus
Step offs Subcutaneous air
Facial stability Cutaneous anesthesia
 Maxillofacial Trauma-Physical Exam
Periorbital and Orbital
Exam
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 Arch fracture
Tripod 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
Often multiple Plain films
Malocclusion Panorex
Intraoral lacerations CT
Sublingual ecchymosis
Nerve injury Open Fractures
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. Ramus
b. Coronoid process
c. Body
d. Angle
e. Symphysis
2. Orbital fractures can cause all of the
following except:
a. Blindness
b. Motor palsies
c. Facial anesthesia
d. Enophthalmos
e. Hyphema
3. Which of the following is/are true
regarding maxillary fractures?
a. Only minimal force necessary
b. Rarely cause CSF rhinorrhea
c. May cause facial lengthening
d. Usually the only sustained injury
e. All of the above are true
4. The best modality for diagnosing an orbital
or facial fractures is
a. Plain films
b. MRI
c. CT
d. Ultrasound
e. 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