SHORTCASE

TRAUMA MAXILOFACIAL
 Identity

Name : Ny. S

Age : 55 Years

Sex : Female

Admission : November 2022

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

 HISTORY
Chief Complain : open wound in facial regio

History :
The patient came with post traffic traged

MOT :
On Saturday 5/11/22 around, at 22.00 WITA, the patient was riding a motorbike with moderate
speed without wearing a helmet heading home from his workplace, at that time the patient was hit
from the front by a drunk driver, and the patient was thrown onto the road

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 compos mentis, with
severe illness, GCS E4V5M6

BP 140/80, Heart rate 83x/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 vulnus laceratum in frontoparietal dextra , size 2x0,5 cm. 1x0,5 c,m with irregular

01
edges
- there is a vulnus laceratum on the frontoparietal size 4x0,5 cm. 1x0,5 c,m with irregular 02
edges

Step Off:
Meet our Enrollment
- Rima orbita superior : Tenderness (-) crepitation (-)

03
- Rima orbita inferior: Tenderness (-), crepitation (-)
teachers
- Frontonasal : Tenderness (-), crrepitation (-) process
- Nasal: Tenderness (-), crepitation (-)
You can describe the topic of
- Zygomaticum : Tenderness (-), crepitation (-)
the section here
04
You can describe the topic of
the section here
 Localized State
Intraoral Region
• Inspection: trismus (-), avulsi (-) maloklusi (+)
• Palpation: tenderness (+)
• Palpasi (Step Off) :
• Unstable maxilla : (+)
• Unstable mandibulla : (+)
 LABORATORY EXAMINATION

Routine Blood (18/10/2022)

• WBC : 13.55 x10³

• RBC : 3.4 x 10⁶
• HB : 10.0
• HCT : 49,0
• MCV : 78,3
• MCH : 28,80
• MCHC : 36,7
• PLT : 297 x 10³
Blood Chemistry

• Glucose level : 142 mg/dl

DIAGNOSIS
TRAUMA MAXILOFACIAL
MANAGEMENT
Planning :
- IVFD RL 1000 cc/24 jam
- Inj. Ceftriaxon 1 g/12j/iv
- Inj. Ranitidin 50 mg /8jam/iv
- Inj. Ketorolac 30 mg/8jam/iv
- Repair soft tissue
 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
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