Maxillofacial Injuries

Maxillofacial Injuries

Face = ‘Crumple zone for Cranium’

Injuries + Complications:

• Airway

• Cervical spine

• Bleeding

• Head injury

• Brain injury

• Poly-trauma

• Secondary Deformity

Commonest cause of carotid dissection in <25 year olds

Bungee jump → Rapid acceleration → Big pulsation in Carotid artery → Dissection

Implications of trauma

• Litigation

• Compensation to individuals who received surgery with substandard outcomes

• Social implications

• Newsworthy

Case of Princess Diana’s security, Trevor Rees-Jones having had facial reconstruction by French OMF surgeon Luc Chikhani following the car crash in 1997.

Key terminology

Laceration = wound caused by BLUNT TRAUMA

• Different to a CUT

• Edges irregular

• Associated with bruising and often underlying hard tissue injury

Therefore when there’s a large cut, prior to stitching the skin, assess the area for a fracture

• If fractures are missed there can be significant complications

• Fracture of frontal bone in a patient could end up with a CSF leak and consequently a mucocele if not repaired beforehand

Stab = Depth > Width

Slash = Width > Depth

Hard Tissue fractures = Breakage of hard tissue (usually bone) either complete or incomplete

Simple = Clean break with minimal disruption to surrounding soft tissues

Compound = Fracture with breach of overlying soft tissues, usually skin but can be oral mucosa

Comminuted = Bone broken in ≥2 pieces, usually a reflection of the magnitude of the fracturing force (associated with a greater degree of injury (bone loss may need grafting/composite reconstruction)

Contaminated = Comminuted fracture with clear ingress of foreign body, much greater risk of infection = Poor prognosis

Classification of injury

• Low impact - Blunt trauma - boot/fist/baton

• High impact - Ballistic (high/low velocity) RTA pedestrian vs car often with poly trauma (neck/spine/limbs) - rare to see high velocity rounds, as will cause immediate mortality

• Blast/explosion - Complex injury patterns, usually with burns, gross contamination

  • Gun powder in wound

  • Check for tissue loss, don’t chuck anything away ‘if black it can still be viable’

  • Drains to prevent dirty wound from becoming infected

  • Mixture of bony and soft tissue injury

Orbital Blowout fractures

• Result of a direct blow to the orbit

• Rapid increase in intraorbital pressure

• Decompression occurs by fracture of ≥1 containing walls of the orbit

• High index of suspicion and prompt identification important to prevent oculocardiac reflex in a trapdoor fracture (triad of bradycardia, syncope and nausea)

Mandibular fracture sites

• Condyle is the commonest site of fracture

• Fractures will typically occur at the weakest point of the bone

• Angle and Symphysis also common

Le Fort Fractures (source radiopedia)

Discovered by Rene Le Fort applying blunt force of different magnitudes on cadaveric faces

Le Fort I 🙊

• Horizontal alveolar ridge (tooth bearing part of maxilla)

• Fracture line through alveolar ridge, lateral nose and inferior wall of maxillary sinus

Le Fort II 🙈

• Pyramidal (nasofrontal suture apex + teeth are pyramid base)

• Fracture arch passes through the posterior alveolar ridge, lateral walls of maxillary sinuses

• Inferior orbital rim and nasal bones

• Uppermost fracture line can pass through the nasofrontal junction or frontal process of maxilla

Le Fort III 🙉

• Craniofacial disjunction

• Transverse fracture line passing through nasofrontal suture, maxillo-frontal suture, orbital wall and zygomatic arch/zygomaticofrontal suture

• Involvement of zygomatic arch, risk of temporalis muscle impingement

• Type III fractures have highest rate of CSF leak

Memory aid:

• Le Fort I is a floating palate (horizontal)

• Le Fort II is a floating maxilla (pyramidal)

• Le Fort III is a floating face (transverse)

Maxillofacial trauma examination

Start at the top and work your way down

1. Scalp → skull, forehead

2. Eyes → pupils, vision, position, movements

3. Ears → hearing, bleeding, CSF, haemotympanum

4. Zygomas → Deformity, steps, other signs of fracture

5. Nose → Deformity, bleeding, CSF, airway and septum

6. Maxilla → Solid or Mobile? Steps, bruising, swelling , bleeding

7. Mandible → Deformity, tenderness, bruising, swelling steps, movement, dental occlusion

8. Mouth to check for above + dental and dentoalveolar injuries

9. Soft tissue injuries → Site, size, nature, position, related structures

10. Facial sensation → Cranial nerve V (Va, Vb, Vc)

11. Facial movement → Cranial nerve VII (5 branches TZBMC)

Maxillofacial trauma aetiology

• Interpersonal violence

• Sports

• Falls

• RTA

• Industrial accidents

• Iatrogenic

• Armed conflict/Civil unrest

• Male:Female ratio = 2.1:1

Evidence based from BAOMS UK survery of facial injuries in 1997, BAOMS UK survey from previous decade echoes the same aetiology

Faris Ghafoor FY2