Dr. Esam Ahmad Z. Omar BDS, MSc-OMFS, FFDRCSI. Monitor the vital signs. Monitor the vital signs. Complications of Facial Traumas.

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1 Complications of Facial Traumas 1) Immediate Complications 2) Late Complications Dr. Esam Ahmad Z. Omar BDS, MSc-OMFS, FFDRCSI Assistant Professor Oral & Maxillofacial Surgeon Taibah University Monitor the vital signs Complications It is essential to monitor the vital signs for all trauma patients, it may help in detection of other serious injuries. 1) Heamodynamic : H.R., B.P. 2) Temperature 1) Local Complications 2) Systemic Complication: a) Related to Trauma b) Related to Systemic conditions Stabilization of associated injuries C-spine injury is primary concern with all maxillofacial trauma victims 1) Any patient with injury above clavicle or 2)head injury resulting in unconscious state 3)Any injury produced by high speed 4)Signs/symptoms of C-Spine injury Neurologic deficit Neck pain Monitor the vital signs When the patient heamodynamically not stable this may indicate for other serious injuries: so the following investigation become indicated: 1) Abdominal ultra-sounography. This module of investigation is indicated for all RTA Patients 2) Cranial C.T. Scan. This module of investigation is indicated for all patients have clinical signs of head injuries 3) a)chest x-ray b) Lateral Cervical Spine x-ray c) P-A Cranial view d)pelvis view should be done for all maxillofacial trauma patients 1

Lateral C-Spine Film Stabilization of associated

$proper immobilization until vertebral fractures$ or spinal cord injuries ruled out Lateral C-spine

$fractures may cause tearing in the Nasal Mucosa$ Airway Factors influence the selection of Airway

injuries 2) Level consciousness of the patient 3)

2 Lateral C-Spine Film Stabilization of associated injuries C-spine injury suspected Avoid any movement of spinal column Establish & maintain proper immobilization until vertebral fractures or spinal cord injuries ruled out Lateral C-spine radiographs CT of C-spine Neurologic exam Airway Obstruction C-spine CTs 10 Blood Loss All Le Fort fractures may cause tearing in the Nasal Mucosa Airway Factors influence the selection of Airway maintenance modalities: 1) Cervical Spine injuries 2) Level consciousness of the patient 3) Availability of upper airway 4) The needs for Trachio-pulmonary toilet 5) Presence of concomitant Systemic injuries 6) Possibility of prolonged hospitalization 2

3 Treatment of Blood Loss & Shock Management of Nasal Bleeding -Hemorrhage most common cause of shock after injury -Multiple injury patients have hypovolemia -Goal is to restore organ perfusion and nourishments Shock 16 3

4 Classifications of Neural Injuries -Subarachnoid bleeding -Intra-cerebral bleeding -Sub-dural bleeding -Epi-dural bleeding Neural injuries ( Intra-cerebral bleeding) Neural injuries ( Subarachnoid bleeding) 4

5 Cerebro-spinal Fluid Rhinorrhoea ( C.S.F) Neural injuries (sub-dural& Epidural bleeding Diagnosis of Maxillofacial Injuries INSPECTION Hemorrhage Otorrhea Rhinorrhea Contour deformity Ecchymosis Edema Continuity defects Malocclusion 5

6 Corticosteroid Insufficiency Diabetic patients End of Part one Physiology- Oral Anticoagulants INR PTR= PT. normal PT of the lab INR=(PTR)ISI Eastman Dental Institute, London Soft tissue injury Facial lacerations not complicated by associated injury can be managed in an ER setting Large extensive facial and scalp lacerations are preferably closed in an operating room environment Part 2 Local Complications 6

$fracture lines Allows$ probable points of

$segmental fractures,$

7 Facial lacerations Associated Soft Tissue Injury Remember to think in 3D for there are always other structures involved! Lefort Classification Provides uniform method to describe the level of major fracture lines Allows references regarding the probable points of stability for surgical treatment Does not incorporate vertical or segmental fractures, comminution or bone loss Horizontal Buttresses Vertical Buttresses Resist occlusal load 7

8 Lefort I Fracture Transverse Maxillary LeFort Fractures Experimentally determined weak points Can be in combinations bilaterally Useful descriptor Results from anterior forces Lefort III Fracture Craniofacial Dysjunction Lefort II Fracture Pyramidal Complications Orbital Complications Bleeding and echymosis 8

9 Orbital Blowout Injury Usually inferior and/or medial wall Cone will become more spherical Leads to enophthalmos, inferior displacement Muscle entrapment causes diplopia Anatomy of the Orbit When the Orbital floor become involved. Orbital Blowout Injury Orbital Blowout Injury Zygoma Fractures Zygoma Fractures Impacted zygoma may mask orbital floor defect Results from lateral forces 9

5 cm behind rim Floor is concave and then

Diplopia, Anatomy of the Orbit Four-sided

10 Anatomy of the Orbit Maximum vertical dimension 1.5 cm behind rim Floor is concave and then convex Enophthalmos, Proptosis. Diplopia, Anatomy of the Orbit Four-sided pyramid or cone Diplopia Dipolpia what is the forced duction test? indication? To rule out the entrapment of inferior rectus muscle. Causes: 1) Entrapment of inferior rectus muscle 2) nuero-muscular injuries 3) Significant changes in orbital volume 4) Retro-ocular oedema and/or bleeding Complications Anatomy of the Orbit Floor slopes into medial wall Optic nerve superomedial to true apex 10

Best done 7-10 days Other indications 1-2 sq.

retinal tear, globe perforation only seeing eye

forced duction Obvious enophthalmos Comminuted

Combined floor/medial wall defects by CT Fracture of

or CT CAD-CAM Technology the best method for orbital

11 Best done 7-10 days Other indications 1-2 sq.cm of floor disrupted Contraindications hyphema, retinal tear, globe perforation only seeing eye medically unstable Need to support floor full 4 cm Orbital Floor When to explore? (Shumrick study) Persistent diplopia with positive forced duction Obvious enophthalmos Comminuted orbital rim by CT >50% floor disruption by CT Combined floor/medial wall defects by CT Fracture of zygoma body by CT Blow-in fx with exophthalmos by PE or CT CAD-CAM Technology the best method for orbital reconstruction currently present. Orbital Floor Dotted line shows anatomic goal of restoration Stereolithography 3D CT 11

12 Dacryocystitis Epiphora Nasal-Orbital-Ethmoid (NOE) Fractures Usually not isolated event Frequently associated with multiple midface fractures Secondary to traumatic insult to radix area of nose Low resistance to directional force gm necessary to produce fracture9 Telecanthus 12

13 Ophthalmologi c Exam Nasal complications Ophthalmologic Exam Fluorescsein reveals corneal abrasion Ophthalmologi c Exam Hyphema is blood in anterior chamber Hx - vision worse supine, clears upright Can cause increased IOP Ophthalmologic Exam Dislocated lens Ophthalmologic Exam Iridodialysis (torn iris Opacified cornea 13

$indicate orbital fracture TMJ and$ TMJ Ankylosis details of

14 Ophthalmologi c Exam Ophthalmologic Exam - Retinal detachment - Traumatic Retinal Edema - Traumatic Pigmentary Retinopathy - Retinal & Vitreous Hemorrhage Increase: angle recession, hyphema, blockage, g.c.glaucoma. decrease : Cyclodialysis, scleral rupture, ciliary body, choroidal effusion Non-union, Infection 1) local causes? 2) Systemic Causes? Ophthalmologi c Exam Subconjunctival ecchymosis may indicate orbital fracture TMJ and management of condylar Fractures TMJ Ankylosis details of managements Conditions may lead to spread of infections (Systemic Conditions) 14

Nerve Damage Special considerations in management of TMJ Fractures 1) Age of the patients 2) presence of malocclusions 3) Deviation during function 4) Pain Incidence of Ankylosis and

15 Nerve Damage Special considerations in management of TMJ Fractures 1) Age of the patients 2) presence of malocclusions 3) Deviation during function 4) Pain Incidence of Ankylosis and possible associated Retrognathia is high in children so long immobilization should be avoided Thank you Esam Ahmed Z. Alomar BDS, MSc-OMFS, FFDRCSI The Royal College of Surgeons, Dublin 15

Clues of a Ruptured Globe

Clues of a Ruptured Globe Definition any eye that has sustained a full thickness traumatic disruption of the cornea or sclera Overwhelmingly, rupture accidents occur in young men, small children and the elderly Corneal laceration