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VIVEK SHRIHARI
Facial Fractures
Phases
Emergency Treatment
Airway
Edema Teeth Blood FB Mandible fracture tongue to pharynx Stridor, hoarseness, retraction, drooling ETT Tracheostomy Long term IMF Cricothyroidotomy
Facial Fractures
Hemorrhage
Anterior cranial fossa Midface Lacerations Nasal
Nasal, zygomatic, orbital, frontal, NOE, maxillary
Reduction (IMF) Anterior/ posterior packing x 24-48 hrs Compression dressing Embolization Bilateral external carotid/ superficial temporal ligation Blood factor replacement
Facial Fractures
Aspiration
Other
Facial Fractures
Early injury care
History PE
Facial Fractures
Classification
Anatomy Closed v. open Le Fort
Radiography
CT v. x-rays
Occlusion/ dentition
Facial Fractures
Mandible
Anatomy
Facial Fractures
Mandible
Anatomy
Facial Fractures
Mandible
Anatomy
Facial Fractures
Mandible
Anatomy
Facial Fractures
Mandible
Most common facial fracture after nasal 10-25% of all facial fractures Body> angle> condyle> parasymphysis> other M: F = 2: 1 58% multiple (93% , 3 fx) Preinjury relationships Stable bony union Facial proportions Avoid complications
Facial Fractures
Mandible
History
Previous trauma Previous baseline Pre-injury photo
Facial Fractures
Mandible
PE
Crepitance Symmetry Tenderness Oral/ dental missing teeth Step offs
Facial Fractures
Mandible
Radiography
Panorex CT Plain films
Mandible
Treatment
Restore form and function
Occlusion, TMJ function, cosmesis
ORIF
Exact anatomic reduction Allows early resumption of mandibular function
Mandible
Mandible
Treatment
Closed Dependent on splinting to maxilla to restore centric occlusion (maximal intercusspation) If inadequate number of teeth,Gunning splint may be needed for IMF
Mandible
Treatment
Open
Accurate reduction
Within 2 weeks If maxilla cannot be used then mandible first or splints Traumitizes gingiva Impairs oral hygiene periodontal disease Uncomfortable Forces can alter tooth position and periodontal attachments Great aspiration risk Contraindication in COPD, seizure d/o, impaired MS Articular surfaces under compression cause pressure necrosis
Mandible
ORIF
Lag screw Anterior
Mandible
ORIF
Reconstruction plate Comminuted body
Mandible
ORIF
Two plate/ tension band Angle
Mandible
ORIF
Dynamic compression plate - Condyle
Mandible
Treatment
Contraindications to open
Not required Not candidate
Facial Fractures
Mandible
Treatment by type
Simple
CR + IMF x 8 weeks if reliable (unreliable avoid IMF and open)
Mandible
Treatment by type
Complex
Multiple or segmental
Difficult to reduce
Mandible
Treatment by type
Complex
Bilateral fracture each hemi-mandible
Simultaneous reduction may be required to avoid magnification of discrepancy Arch bars and IMF may worsen Consider reducing one or both condyles first if difficult to control flaring the inferior border Close fractures two plates Separated fractures long spanning plate
Mandible
Treatment by type
Complex
Comminuted
High energy GSW, SGW, MVC Easy to devitalize small fragments Difficult to accurately reduce Large reconstruction plate may be required Temporary external fixator may be used if condition of patient or soft tissue requires Bone graft for extensive loss Pre-treatment infection: Debride small fragments Post-treatment infection: FB (bone or screw)
Mandible
Treatment by type
Complex
Edentulous
Atrophied and osteopenic poorer healing Early atherosclerosis (15 years) of inferior alveolar artery 20% non-union Simple and undisplaced pureed diet and obs Use dentures or splints Rigid fixation with spanning reconstruction plate Bone graft/ flap within 5 years Soft tissue repair and IMF or ex fix until ready
Mandible
Treatment
Infection
More common if delayed care Abx, debridement Fracture line may resorb and form gaps larger plates Extreme cases may require external fixator with secondary ORIF +/- graft
Mandible
Treatment
Children
Most need CR + immobilization (single arch bar or lingual splint) x 2 weeks Conical shape makes arch bars less useful Indications for ORIF
Mandible
Treatment
Children
Condyle is growth center of mandible Trauma can cause hemarthrosis ankylosis Intracapsular fractures that do not alter the centric occlusion should not be immobilized to avoid ankylosis which can occur >12 months later and requires aggressive treatment Unilateral condylar fractures with altered centric occlusion are treated with arch bars or lingual splints and elastics Displaced bilateral condylar fractures with posterior vertical collapse and anterior open bite deformity require CR + IMF x 4 weeks
Mandible
Treatment
By Location
Alveolar Process (1%)
Remove if devitalized o/w IMF or splint Often associated with condylar fractures Significant forces cause lateral flaring of posterior segments (often worse with IMF) Often associated with contralateral fractures Mental nerve Burr/ osteotome may help lessen anterior curvature
Symphysis (5.8%)
Parasymphysis (11.6%)
Mandible
Treatment
By Location
Body (31.9%)
May require external approach Bi-cortical plates placed beneath mental canal May require external approach Often associated with contralateral Highest complication rate due to third molar teeth and displacing forces
Angle (27.5%)
Mandible
Treatment
By Location
Ramus (2.5%)
Usually require extraoral approach Often stable due to splinting effect of massetermedial pterygoid muscle sling unless displacement causes vertical shortening (telescoping) Soft diet usually enough Severe pain may require brief IMF
Mandible
Treatment
By Location
Condyle (23.8%)
Proximal segment can undergo AVN Intra-articular fractures: Very difficult ORIF, OA is common outcome, usually brief IMF for malocclusion o/w early mobilization +/- elastics Condylar neck: Anteromedial displacement of proximal segment by lateral pterygoid, usually treated with IMF x 6 weeks, ORIF if joint capsule is thought to be involved
Mandible
Treatment
By Location
Condyle
ORIF Displaced in to middle cranial fossa FB within joint Lateral extra-capsular displacement of condyle Displacement blocking opening or closing Posterior vertical shortening of mandible with open bite after 2 week IMF trial Relative Bilateral associated with unstable midface fractures Bilateral edentulous without splint
Mandible
Postoperative care
+/- Abx, airway control with IMF (wire cutters), HOB (secretions) + ice pack for edema
Diet
CLD blenderized, 48o IVF, 15 lb wt loss
Splints/ IMF
Oral hygiene (peridex, H2O2, brush), remove wax
Oral washouts
Release IMF q 3-5 days if needed
Mandible
Centric occlusion
Remove IMF to assess ORIF
Therapeutic rehabilitation
Regain strength and mobility, PT if severe (prolonged IMF or condyle fracture) Dental treatment (missing teeth)
Complications
Malocclusion, malunion, non-union, hardware exposure, infection, non-compliance
Mandible
Teeth in fracture line
Facial Fractures
Frontal bone anatomy 7 bones
Facial Fractures
Frontal bone anatomy
Facial Fractures
Frontal sinus anatomy
Middle meatus
Facial Fractures
Frontal Sinus
MVC - Assaults 2-3 x force to fracture lower frontal sinus Other injuries associated (1/4 die in 14d) Rare in children
Facial Fractures
Frontal Sinus Fracture
Signs
Rhinorrhea Step-off Supraorbital anesthesia Subconjunctival hematoma Subcutaneous crepitance
Facial Fractures
Frontal Sinus Fracture
Diagnosis
Plain films CT
Facial Fractures
Frontal sinus fractures
Anterior Table (Thick)
Displaced ORIF Blockage of nasofrontal duct (methylene blue)
Remove mucosa Bone graft nasofrontal ducts, fill space Elevate and fixate bone
Facial Fractures
Frontal Sinus Fracture
Complications (Posterior > anterior)
Acute
Epistaxis CSF leak Meningitis Intracranial injury Hematoma Mucocele Sinusitis Osteomyelitis Abscesses
Subacute
Chronic
END