MAXILOFACIAL

TRAUMA
Presenter:
- Wisnu Adiputra (07120080072)
- Nofilia Citra Candra (07120090066)

BHAYANGKARA TK. I RADEN SAID SUKANTO HOSPITAL

FACULTY OF MEDICINE PELITA HARAPAN UNIVERSITY
JAKARTA

Definition of Trauma
A term derived from the Greek for

WOUND
It refers to any bodily injury.
It defined as tissue injury due to direct
effects of externally applied energy.
Energy may be mechanical, thermal,
electrical, electromagnatic or nuclear.
Included:burns, drowning, smoke,
inhalation,
slip & fall.
Excluded: poisoning/toxic ingestion.

Initial Assessment

SURVEY

Survey
Safe?

What
happen?

Count the
victim
How many
helper?
Help

TRIAGE
Black or white: Dead
Red:patient with heavy trauma, combusio with

high BSA
Yellow : extremity fracture without heavy
hypovolemic shock
Green: minimal trauma

PRIMARY SURVEY
A : Airway with cervical spine protect.
B : Breathing
C : Circulation --control external bleeding.
D : Disability or neurological status
E : Exposure (undress) & Environment

(temp control)

Glasgow coma scale (GCS)

(Teasdale and Jennett, 1974)

Eye
opening

Motor
response

Verbal
response

Spontaneous 4 Move to
command

6 Converse

To speech

3 Localizes to
pain

5 Confused

To pain

2 Withdraw
from pain

4 Gibberish

none

1 flexes

3 grunts

2 none
1

Extends
none

Score 8 or less indicates poor prognosis, moderate head injury

between 9-12 and mild refereed to 13-15
8

Airway
LOOK
LISTEN
FEEL

Airway
Is there any obstruction?
Protection of the spine & spinal cord is the

important management principle.

Do chin lift or jaw thrust
GCS < 8 consider of definitive airway
Can talk = airway clear

Indication For Definite Airway

* Unconscious
* Severe maxillo-facial fracture
* Risk for aspiration : Bleeding/ vomiting
* Risk for obstruction : neck hematoma/laryngeal,tracheal
injury/ stridor
* Apnea : Neuromuscular paralysis/unconscious
* Inadequate respiratory effort:
tachypnea/hypoxia/hypercapnia/cyanosis
* Severe closed head injury need for hyperventilation

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BREATHING
Breathing dan Ventilasi
Chest expansion
Auskultasi (if possible)
Percussion : hyporesonance(fluid) dan
Hyperesonance(air)

8 lethal Injury
1. Simple pneumothorax
2. Hemothorax
3. Pulmonary contusion
4. Tracheo-bronchial tree injury
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Mediastinal traversing wounds.

Breathing Interventions
Ventilate with 100% oxygen
Needle decompression if tension

pneumothorax suspected
Chest tubes for pneumothorax / hemothorax
Occlusive dressing to sucking chest wound
If intubated, evaluate ETT position

CIRCULATION
Circulation
Hemorrhagic shock should be assumed in any hypotensive trauma patient
1. Blood Volume & Cardiac Output
a. level of consciousness.
b. skin color and capillary refill
c. Pulse.: Normal ( 60-100x/min)
Tachycardi ( >100x/min
Bradycardi ( <50x/min)
2. Bleeding
*external bleeding is identified & controlled in the
primary survey.
*Tourniquets should not be use.

Normal Blood Amount:

Normal adult blood volume : 7% of body weight
Normal blood volume for child : 8-9% of body weight

Hemorrhage Classification :
Class I Hemorrhage :

up to 15% loss

Class II Hemorrhage :

15-30% loss

Class III Hemorrhage : 30-40% loss

Class IV Hemorrhage : >40% loss

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Circulation Interventions
Cardiac monitor
Apply pressure to sites of external

hemorrhage
Establish IV access

2 large bore IVs

Central lines if indicated

Cardiac tamponade decompression if

indicated
Volume resuscitation

Have blood ready if needed

Level One infusers available

3 for 1 Rule
a rough guideline for the total
amount of crystalloid volume acutely
is to replace each ML of blood loss
with 3 ML of crystalloid fluid, thus
allowing for restitution of plasma
volume lost into the interstitial &
intracellular space

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20

Initial Fluid Therapy

Lactated Ringer is preferred

* For adult 1-2 liters

bolus
* For child 20ml/kg
bolus
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21

Disability
Disability ( Neurological Evaluation)
Simple Mnemonic to describe level of consciousness
A : Alert
V : Responds to Vocal stimuli
P : Responds to Painful stimuli
U : Unresponsive to all stimuli
Not forget to use also Glascow Coma Scale.

Disability Interventions
Spinal cord injury
High dose steroids if within 8 hours
ICP monitor- Neurosurgical consultation
Elevated ICP
Head of bed elevated
Mannitol
Hyperventilation
Emergent decompression

EXPOSURE
Exposure / Environmental Control
-It is the pts body temp that is most important, not he
comfort of the health care provider.
-Intravenous fluid should be warm.
-Warm environment (room tem) should be maintained.
-early control of hemorrhage.
-Complete disrobing of patient
-Logroll to inspect back

E- Exposure
Complete disrobing of patient
Logroll to inspect back
Rectal temperature
Warm blankets/external warming device to

prevent hypothermia

Always Inspect the Back

RESUSCITATION
A. Airway
*definite airway if there is any doubt about the pts ability to

maintain airway integrity.

B. Breathing /Ventilation/Oxygenation
*every injured pt should received supplement oxygen
C. Circulation
*control bleeding by direct pressure or operative intervention
* minimum of two large caliber IV should be established
*pregnancy test for all female of child bearing age.
* Lactated Ringer is preferred & better if warm. 3 for 1 rule

Secondary survey
Although maxillofacial injuries is part of
the secondary survey, OMFS might be
involved at early stage if the airway is
compromised by direct facial trauma
Head Injury
Facial injury
Chest Injury
Abdominal injury
Injury to extremities
29

Facial Trauma SECONDARY

SURVEY
History: Three key questions
Vision changes?
Monocular double vision
Lens disruption, or corneal or retinal injury
Binocular double vision
Dysfunction of extraocular muscles or nerves
Pain w/ movement = injury to orbit or globe

Facial numbness
Trigeminal branch nerve injury
Malocclusion

Fracture or dislocation

Facial Trauma Evaluation

Physical Exam
Inspection
Facial elongation (Donkey Face) associated with
high grade Le Forte fractures
Facial asymmetry - neural involvement
Ecchymosis - Raccoons eyes or Battles sign

Palpation

Assess for tenderness, crepitus or subcutaneous air

Intraoral exam for zygomatic arch injury and
maxillary stability

Facial Trauma Evaluation

Physical Exam

Orbital examination
Done early before swelling
Pupil reactivity
Tear drop pupil associated with globe rupture
Marcus Gunn pupil
Hyphema
Visual acuity
EOM
Ocular muscle entrapment
Ocular nerve injury
Pain can be a clue to associated orbit fractures
Proptosis - consider retrobulbar hematoma

Facial Trauma Evaluation

Physical Exam - Orbital
Examination
Lid Lacerations
Medial

High risk for lacrimal duct

involvement

Upper

third of lower eyelid

and Lower Eyelid

Disruption of tarsal plate or

cartilaginous plate

Grays Anatomy (Wikipedia)

Eyelid

Droop
Disruption of levator
palpebral muscle
Grays Anatomy (Wikipedia
)

Facial Trauma Evaluation

Physical Exam
Nose
Septal

Requires immediate evacuation to prevent pressure

necrosis of the nasal septum

CSF

hematoma

Rhinorrhea

Indicates cribriform plate disruption

Deformity

Indicates nasal bone fracture

Ears
CSF

leak
Hemotympanum
Battles sign - indicates basilar skull fracture

Facial Trauma Evaluation

Physical Exam

Mandible/Dentition

Malocclusion
Flail mandible - two separate fracture site
TMJ dislocation - typically anterior
Tongue blade test
Patient bites down on tongue blade and it is
twisted until it breaks:
Unable to break tongue blade indicates
mandibular fracture
95% sensitive; 65% specific for mandibular
fracture
Loose/chipped teeth

Secondary Survey
Neurologic
Skin fold symmetry at rest
Motor: each division of CN-VII
Sensation: 3 divisions of CN-V
Sensation on tongue
Gag reflex

Facial Trauma - Imaging

Plain films

Challenging to read
Approach
Asymmetry
Bony

integrity
Subcutaneous air
Sinus opacity
Teardrop sign - orbital fat herniation

Facial Trauma - Imaging

Plain films
Waters or occipital-mental view
As sensitive a entire facial series
Examines orbital rims and air/fluid levels
PA or Caldwell view

Best for upper facial bones

Submental-vertex (jug handle) view

Best to evaluate for zygomatic arch fractures
Towne view

Evaluation of mandibular ramus

Waters

Jug Handle

Facial Trauma - Imaging

CT
Considered by some

to be one of the two

most important
advancements in
the last 20 years.
Helps guide surgical
management

RadiologyInfo.o
rg

Head injury
Many of facial injury patients sustain
head injury in particular the mid face
injuries
Open
Closed
it is ranged from Mild concussion to brain
death

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Signs and symptoms of head injury

Loss of conscious

OR
History of loss of conscious
History of vomiting
Change in pulse rate, blood pressure and
pupil reaction to light in association with
increased intracranial pressure
Assessment of head injury (behavioral

responses motor and verbal responses

and eye opening)

Skull fracture
Skull base fracture (battles sign)
Temporal/ frontal bone fracture
Naso-orbital ethmoidal fracture
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Cervical spine injury

Can be deadly if it involved the
odontoid process of the axis bone of
the axis vertebra
If the injury above the clavicle bone,
clavicle collar should minimize the
risk of any deterioration
Pt with maxillofacial or head trauma should
be presumed
to have and unstable cervical spine.
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Breathing and ventilation

Chest injuries:
Pneumothorax, haemopneumothorax, flail
segments, reputure daiphram, cardiac
tamponade

signs
Clinical
Deviated trachea
Absence of breath
sounds
Dullness to percussion
Paradoxical movements
Hyper-response with
a large pneumothorax
Muffled heart sounds

Radiographical
Loss of lung marking
Deviation of trachea
Raised hemi-diaphragm
Fluid levels
Fracture of ribs
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Emergency treatment in case

of chest injury

Occluding of open chest wounds

Endotreacheal intubation for unstable flail

chest

Intermittent positive pressure ventilation

Needle decompression of the pericardium
Decompression of gastric dilation and

aspiration of stomach content

46

Hemorrhage
Acute bleeding may lead to hemorrhagic
shock and circulatory collapse

Abdominal and pelvis injury; liver and

internal organs injury (peritonism)

Fracture of the extremities (femur)

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Abdomen and pelvis

In addition to direct injuries, loss of
circulating blood into peritoneal
cavity or retroperitonial space is life
threatening, indicated by physical
signs and palpation, percussion and
auscultation
Management:
Diagnostic peritoneal lavage (DPL) to
detect blood, bowel content, urine
Emergency laparotomy
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Abdominal Trauma
Look for distension, tenderness, seatbelt

marks, penetrating trauma, retroperitoneal

ecchymosis
Be suspicious of free fluid without evidence of
solid organ injury

Extremity trauma
Fracture of extremities in particular
the femur can be a significant cause
of occult blood loss. Straightening
and reduction of gross deformity is
part of circulation control
Cardinal features of extremities injury
Impaired distal perfusion (risk of ischemia)
Compartment syndrome (limb loss)
Traumatic amputation
50

Patient hospitalization and

determination of priorities
Facial bone fracture is hardly ever an urgent procedure,
simple and minor injury of ambulant patient may
occasionally mask a serious injury that eventually
ended the patients life

emergency cases require instant

admission
conditions that may progress to
emergency
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Preliminary treatment in complex

facial injury
Soft tissue laceration (8 hours of injury with no

delay beyond 24 hours)

Support of the bone fragments

Injury to the eye
As a result of trauma, 1.6 million are blind, 2.3
million are suffering serious bilateral visual
impairment and 19 million with unilateral loss of
sight (Macewen 1999)

Ocular damage
Reduction in visual acuity
Eyelid injury
52

Prevention of infection
Fractures of jaw involving teeth bearing areas
are compound in nature and midface fracture
may go high, leading to CSF leaks (rhinorrhoea,
otorrhoea) and risk of meningitis,
and in case of perforation of cartilaginous
auditory canal
Diagnosis:

Laboratory investigation, CT and MRI scan

Management:
Dressing of external wounds
Closure of open wounds
Reposition and immobilization of the fractures
Repair of the dura matter
Antibacterial prophylaxis (as part of the general management

(Eljamal, 1993)

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Control of pain
Displaced fracture may cause severe pain but
strong analgesic ( Morphine and its derivatives)
must be avoided as they depress cough reflex,
constrict pupils as they may mask the signs of
increasing intracranial pressure

Management:
Non-steroidal anti-inflammatory drugs can
be prescribed (Diclofenac acid)
Reduction of fracture
sedation

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SECONDARY SURVEY
Does not begin until the primary survey

(ABCDEs) is completed, resuscitative effort are

well established & the pt is demonstrating
normalization of vital sign.

SECONDARY SURVEY
History
A : Allergies.
M : Medication currently used.
P : Past illness/ Pregnancy.
L : Last Meal
E : Events/Environment related to the injury.

*blunt trauma/penetrating trauma/injuries due

to cold & burn/hazardous environment?

Fracture Classification
Major
Lefort I, II, III
Mandibular

Minor
Nasal
Sinus wall
Zygomatic
Supraorbital
Orbital floor

Lefort Fractures
Lefort fractures can coexist with additional

facial fractures
Patient may have different Lefort type fracture
on each side of the face

Differentiating Leforts
Pull forward on maxillary teeth
Lefort I: maxilla only moves
Lefort II: maxilla & base of nose move:
Lefort III: whole face moves:

Lefort I: Nasomaxillary
Horizontal fracture extending through maxilla

between maxillary sinus floor & orbital floor

Crepitus over maxilla
Ecchymosis in buccal vestibule
Epistaxis: can be bilateral
Malocclusion
Maxilla mobility

Lefort I: Nasomaxillary
Closed reduction
Intermaxillary fixation: secures maxilla to

mandible
May need wiring or plating of maxillary wall
and / or zygomatic arch
Antibiotics: anti-staphylococcal

Lefort II: Pyramidal

Subzygomatic midfacial fracture with a

pyramid-shaped fragment separated from

cranium and lateral aspects of face

Lefort II: Pyramidal

Signs & symptoms
Midface crepitus
Face lengthening
Malocclusion
Bilateral epistaxis
Infraorbital paresthesia
Ecchymoses: buccal vestibule, periorbital,
subconjunctival

Lefort II: Pyramidal

Hemorrhage or airway obstruction may

require emergent surgery

Treatment can often be delayed till edema
decreased

Lefort II: Pyramidal

Usually require
Intermaxillary fixation
Interosseous wiring or plating of infraorbital
rims, nasal-frontal area, & lateral maxillary
walls
May need additional suspension wires
Antibiotics

Lefort III
Craniofacial dissociation
Bilateral suprazygomatic fracture resulting in

a floating fragment of mid-facial bones, which

are totally separated from the cranial base

Lefort III
Signs and Symptoms
Face lengthening: caved-in or donkey face
Malocclusion: open bite
Lateral orbital rim defect
Ecchymoses: periorbital, subconjunctival

Lefort III
Signs and Symptoms
Bilateral epistaxis
Infraorbital paresthesia
Often medial canthal deformity
Often unequal pupil height

Lefort III
Usually associated with major soft tissue

injury requiring emergent surgery for bleeding

control
Surgery can be delayed till edema resolves
Intermaxillary fixation

Lefort III
Transosseous wiring or plating
Frontozygomatic suture
Nasofrontal suture
May need extracranial fixation if concurrent
mandibular fracture
Antibiotics

Mandible Fractures
Airway obstruction from loss of attachment at

base of tongue
>50 % are multiple
Condylar fractures associated with ear canal
lacerations & high cervical fractures
High infection potential if any violation of oral
mucosa

Mandible Fractures
Signs and symptoms
Malocclusion
Decreased jaw range of motion
Trismus
Chin numbness
Ecchymosis in floor of mouth
Palpable step deformity

Mandible Fractures
Tongue blade test: have patient bite down

while you twist. If no fracture, you will be able

to break the blade.

TMJ Dislocation
Can occur from direct blow to mandible
Can occur spontaneously from yawning or

laughing
Mandible dislocates forward & superiorly
Concurrent masseter & pterygoid spasm

TMJ Dislocation
Symptoms
Patient presents with mouth open, cannot
close mouth or talk well
Can be misdiagnosed as psychiatric or
dystonic reaction

TMJ Dislocation
Treatment
Manual reduction: place wrapped thumbs on
molars & push downward, then backward
Be careful not to get bitten
Usually does not require procedural sedation
or muscle relaxants

Nasal Bone Fractures

Often diagnosed clinically: x-ray not needed
Emergent reduction not necessary except to

control epistaxis
Usually do not need antibiotics
Early reduction under local anesthesia useful
if nares obstructed

Nasal Bone Fractures

Nasal septal hematoma: incise & drain,

anterior pack, antibiotics, follow-up at 24

hours
Follow-up timing for recheck or reduction:
Children: 3 to 5 days
Adults: 7 days

Zygomatic Fractures
Tripod (tri-malar) fracture
Depression of malar eminence
Fractures at temporal, frontal, and maxillary
suture lines

Zygomatic Fractures
Isolated arch fracture
Less common
Shows best on submental-vertex x-ray view
Painful mandible movement
Usually treat with fixation wire if arch
depressed

Zygomatic Fractures
Tripod S & S
Unilateral
epistaxis
Depressed malar
prominence
Subcutaneous
emphysema
Orbital rim stepoff

Altered relative

pupil position
Periorbital
ecchymosis
Subconjunctival
hemorrhage
Infraorbital
hypoesthesia

Supraorbital Fractures
Frontal sinus fracture
Often associated with intracranial injury
Often show depressed glabellar area
If posterior wall fracture, then dura is torn

Supraorbital Fractures
Ethmoid fracture
Blow to bridge of nose
Often associated with cribiform plate fracture,
CSF leak
Medial canthus ligament injury needs
transnasal wiring repair to prevent
telecanthus

Orbital Fractures
Blow out fracture of floor
Rule out globe injury
Visual acuity
Visual fields
Extraocular movement
Anterior chamber
Fundus
Fluorescein & slit lamp

Orbital Fractures
Symptoms and signs
Diplopia: double vision
Enophthalmos: sunken eyeball
Impaired EOMs
Infraorbital hypesthesia
Maxillary sinus opacification
Hanging drop in maxillary sinus

Orbital Fractures
Diplopia with upward gaze: 90%
Suggests inferior blowout
Entrapment of inferior rectus & inferior oblique
Diplopia with lateral gaze: 10%
Suggests medial fracture
Restriction of medial rectus muscle

Orbital Fracture:
Treatment
Sometimes extraocular muscle dysfunction

can be due to edema and will correct without

surgery
Persistent or high grade muscle entrapment
requires surgical repair of orbital floor (bone
grafts, Teflon, plating, etc.)

Bottom to top

Top To Bottom

Facial Soft Tissue Injuries

Before repair, rule out injury to:
Facial nerve
Trigeminal nerve
Parotid duct
Lacrimal duct
Medial canthal ligament
Remove embedded foreign material

Facial Soft Tissue Rules

For lip lacerations, place first suture at

vermillion border
Never shave an eyebrow: may not grow back
If debridement of eyebrow laceration needed,
debride parallel to angle of hairs rather than
vertically

Facial Soft Tissue Rules

Antibiotics for 3 to 5 days for any intraoral

laceration (penicillin VK or erythromycin) and

if any exposed ear cartilage (antistaphylococcal antibiotic) no evidence
Remove sutures in 3 to 5 days to prevent
cross-marks

Facial Soft Tissue Rules

Most face bite wounds can be sutured

primarily
Clean facial wounds can be repaired up to 24
hours after injury
Place incisions or debridement lines parallel
to the lines of least skin tension (Lines of
Langer)

SUMMARY
Assess ABC's first
Do complete exam as part of secondary

survey
Obtain standard X-rays and / or CT scan as
indicated
Decide if specialist referral and / or operative
repair indicated
Arrange followup after repair to assess for
delayed complications or cosmetic problems

THANK YOU