SHORTCASE

TRAUMA MAXILOFACIAL
 Identity

Name : Ny. T

Age : 48 Years

Sex : Female

Admission : 18 Oktober 2022

Doctor in charge: dr. Saktrio D. Subarno, Sp.BP-RE

 HISTORY
Chief Complain : Loss of consciousness

History :
The patient came with loss of consciousness post traffic traged

MOT :
On Thuesday (18/10/2022) at 09.00 WITA the patient was on his way to market with her daughter
and her grandchild by using motorcycle. The patient rides a motorbike at moderate speed and
wearing helmet . When she went to turn left suddenly there is an other motorbike came from
opposite direction and crash them and then patient fall down to the left side and her face hit the
ground.

HOT :
History of unconscious (+)
There was history of nausea and vomiting (+)
History of bleeding from the mouth (+)
History of alcohol consumption (-) drugs (-)
History of wound care (-)
GENERALIZED STATE
The patient was coma, with severe
illness, GCS E1V2M1

BP 180/114, Heart rate 90x/m, reguler,

strong, CRT < 2 second

Respiratory rate 20x/m, symmetric,

regular, SpO2 99%
Temperature 36,8°C (axillary)
 Status Present
Head Neck
• normally • normally

Face Chest
• Localized site • normally

Nose Abdomen
• normally
• normally

Mouth Ekstremitas Superior

• normally
• normally
Ekstremitas inferior
Ears
• normally
• normally
Localazied State
Facial region :
Inspection :
- there is a infra orbita vulnus laceratum infra orbita, size 1 cm with irregular edges

01 02
- there is a vulnus laceratum on the frotntalis size 2x0,5 cm. 1x0,5 c,m with irregular edges
- There is contusion in the labialis sinistra

Step Off:
Meet our
Rima orbita superior: Nyeri tekan(-), krepitasi (-)Enrollment
03
Rima orbita inferior: Nyeri tekan(+), krepitasi (+)
teachers
Frontonasal: Nyeri tekan(+), krepitasi (-) process
Nasal : Nyeri tekan(+), krepitasi (-)
You can describe the topic of
Zygomaticum : Nyeri tekan(+), krepitasi (-)
the section here
04
You can describe the topic of
the section here
 LABORATORY EXAMINATION
Routine Blood (18/10/2022)
• WBC : 19.7 x10³
• RBC : 6.25 x 10⁶
• HB : 18.0
• HCT : 49,0
• MCV : 78,3
• MCH : 28,80
• MCHC : 36,7
• PLT : 251 x 10³
Koagulasic
• Bleeding time : 2’14”
• Freezing time : 8’30”
 LABORATORY EXAMINATION
chemical Blood (18/10/2022)
• WBC : 19.7 x10³
• RBC : 6.25 x 10⁶
• HB : 18.0
• HCT : 49,0
• MCV : 78,3
• MCH : 28,80
• MCHC : 36,7
• PLT : 251 x 10³
Koagulasic
• Bleeding time : 2’14”
• Freezing time : 8’30”
Blood Chemistry
• Glucose level : 131 mg/dl
• SGOT : 63 U/L
• SGPT : 18 U/L
• Ureum : 27 mg/dl
• Kreatinin : 1,1 mg/dl
DIAGNOSIS
TRAUMA MAXILOFACIAL
MANAGEMENT
Planning :
- IVFD D5 ½ Kolf 21 tpm
- Inj. Ceftriaxon 1 g/12j/iv
- Inj. Ranitidin 50 mg /8jam/iv
- Inj. Ketorolac 30 mg/8jam/iv
- Manirol 125 cc/6jam/iv
 Literature Review

Management of maxillofacial trauma presents challenges of its own

which include a need to restore normal occlusion, maintenance of
facial symmetry, and complex movement of the temporomandibular
joint.
Literature Review

Etiology

- Fight
- Traffic accident
- Industrial accident
- penetrating trauma (knife or gunshot
wound)
- violence against children and parents
- domestic violence
 Literature Review
Maxillary Fracture

A Le Fort I fracture is a horizontal maxillary fracture that crosses the inferior aspect of the maxilla and separates the
alveolar process containing the maxillary and hard palate teeth from the rest of the maxilla. The fracture extends through
the lower 1/3 of the septum and includes the medial and lateral maxillary sinuses extending to the pterygoid and palatal
bones.

Le Fort II fracture is a pyramidal fracture that begins at the nasal bone and extends through the ethmoid and lacrimal
bones, descends through the zygomaticofacial suture, continues posteriorly and laterally through the maxilla, under the
zygomaticus and into the pterygoid.

Le Fort III fracture, also known as craniofacial dysjunction, is a separation of all facial bones from the cranial base with
simultaneous fractures of the zygoma, maxilla, and nasal bones. The fracture line extends posterolaterally through the
ethmoid bone, orbits, and pterygomaxillary sutures into the sphenopalatine fossa.
 Literature Review

Management
Treatment for facial trauma is complex and often involves airway
control, bleeding control, reduction of swelling, prevention of
infection, repair of bone fractures, repair of lacerations or soft
tissue injury, and reconstruction.
DOCUMENTATION
THANKYOU