Complications
aspiration
airway compromised
scars
nerve damage
malocclusion
chronic sinusitis
Causes of Mortality
airway compromise
exsanguination
intracranial/c-spine injury
meningitis
oropharyngeal infections
Lefort fx can coexist with
other facial fractures
Pt may have
different lefort fractures on different sides of the face
Lefort I
nasomaxillary
horizontal fx extending through maxilla between maxillary sinus floor and orbital floor
Lefort I Sx
crepitus over maxilla
ecchymosis in buccal vestibule
epistaxis
malocclusion
maxilla mobility
maxilla will move forward with hand pull
Lefort I Tx
closed reduction
intermaxillary fixation: secures maxilla to mandible
may need wiring or plating
anti-staph abx
Lefort II
Pyramindal
subzygmatic midfacial fx with pyramid shaped fragment separated from cranium and lateral aspects of the face
Lefort II Sx
midface crepitus
face lengthening
malocculsion
epistaxis
infraorbital parenthesis
ecchymosis
maxilla and nose will pull forward
Lefort II emergent surgery if
hemorrhage or airway obstruction
Treatment can often be delayed until
edema decreases
Lefort II Tx
intermaxillary fixation
interosseous wiring or plating
suspension wires
anti-staphy abx
intubation if airway comp
Lefort III
craniofacial dislocation
bilateral suprazygomatic fx resulting in a floating fragment of mid-faial bones which are totally separated from the cranial base
Lefort III Sx
face lengthening, cave in, donkey face
malocclusion, open bite
lateral orbit rim defect
echymosis
epistaxis
infraorbital partestheisa
medial canthal deformity
unequal pupil height
entire face will pull forward
Lefort III Tx
emergent surgery for bleeding control
intermaxillary fixation
transosseous wiring or plating
abx
#1 fx of the face
mandible
Mandible fx usually caused by
a direct blow (getting hit/falling)
Mandible Fx Sx
airway obstruction form loss of attachment at base of tongue
Mandible fx > 50% are
multiple
If violation of oral mucosa
high infection potential
So...
start on clindamycin 300 mg TID
follow up with ENT for wiring (regardless of open or closed)
First and second mc mandible fxs
#1 condyle
#2 body
Mandible fx Sx
malocclusion
decreased jaw range of motion
trismus
chin numbness
ecchymosis
palpable step deformity
Mandible fx Dx
tongue blade test
Mandible fx Tx
prompt fixation: intermaxillary fixation +/- wiring or plating
Causes of TMJ Dislocation
direct blow
yawning/laughing
fall on chin
Mandible dislocates
forward and superior
TMJ Dislocation Sx
mouth open, can't close it
can't talk well
drooling
Can be misdiagnosed for
psychiatric or dystonic /prochlorperazine/compaizine reaction
TMJ Dislocation Tx
manual reduction (thumbs around molars push down and back
usually doesn't require sedation or muscle relaxants
Nasal Fx Dx
usually clinical
really only thing on that face that you would XR in ER
Nasal Fx Tx
emergent reduction only to control bleeding, nares obstructed
If septal hematoma
I&D
anterior pack
abx
follow up at 24 hours
Reduction follow up
children: 3-5 days
adults: 7 days
Tripod/Trimalar Fx
depression of malar eminence
fx at temporal, frontal, maxillary suture lines
Tripod/Trimalar Fx Dx
CT
Isolated arch fx
less common
Isolated arch fx Sx
painful mandible movment
Isolated arch fx Dx
best seen on submittal vertex XR
Isolated arch tx
fixation wire
Frontal sinus fx often associated with
intracranial injury
Frontal sinus fx often shows
depressed glabellar area
If posterior wall fx then
dura is torn --> worry about brain/infection
Ethomoid fx cause
blow to bridge of nose
Ethmoid fx often associated with
cribiform plate fx, CSF leak
What needs wiring repair?
canthus ligament injury
Orbital fx
blow out of floor
Rule out
globe injury
Orbital Fx Sx
double vision (90% with upward gaze, 10% with lateral gaze)
enopthalmous
impaired EOM
infraorbital paresthesia
maxillary sinus opacification on exam and scan
hanging drop in maxillary sinus
Diplopia with upward gaze indicates
inferior blowout
entrapment or inferior recuts and inferior olique
Diplopia with lateral gaze indicates
medial fx
restriction of medial rectus
Orbital Fx Tx
persistent or high grade entrapment needs surgery
hyphema
bleeding in the anterior chamber
Soft tissue injury of the face, must remove
embedded FB to prevent tattooing
For lip lacs
first suture at the vermilion border
Never shave
eyebrow
Debride ____ to angle of hairs
parallel
Antibiotics for
3-5 days for intramural or exposed ear cartilage (cloned or augmenting)
Remove sutures in
3-5 days to prevent cross marks
Bite Wound Tx
rabies
clean wounds can be repaired up to 24 hours after
debride parallel
Glass means you should
get an XR
Ellis I
enamel only
painless
white fx surface
Ellis II
enamel and dentin
painful
yellow fx surface
Ellis III
pulp involved
painful
red fx surface
Treatment for Teeth
find tooth
take it from crown without touching root
put it in milk or put it back in place
visit dentist immediately
Dental Abscess/Pain Tx
Abx
NSAIDs
send to dentist
Tongue Lac Tx
abx
not hot foods 24 hours
start with ice cream/popsicles
Consider closing
> 1-2 cm
large gaping wounds
wounds requiring suturing for hemostasis
anterior tongue split
Can have long term
speech deficits
Ear Trauma
hematoma to pinna can lead to cauliflower if not drained