Facial Trauma. Facial Trauma. Facial Trauma

Facial Trauma Facial Trauma Brian Bast DMD, MD Department of Oral and Maxillofacial Surgery University of California, San Francisco School of Dentistry Brian Bast DMD, MD Department of Oral and Maxillofacial Surgery University of California, San Francisco School of Dentistry Residency Program Director Facial Trauma Brian Bast DMD, MD Department of Oral and Maxillofacial Surgery University of California, San Francisco School of Dentistry Chief, San Francisco General Hospital 1

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10-15% of Trauma Patients will have Face Injuries 3

Facial Trauma 25%-30% of Patients with Face Trauma will have other Injuries. Limbs 13% Brain 11% Chest 6% Spine 3% Abd 1% ATLS Airway Globe Antibiotics Admission Multiple Injuries 10% 4

ATLS Airway Breathing Circulation bleeding (maxillary artery) Disability face trauma = head trauma neck trauma Exposure ATLS Airway Breathing Circulation bleeding (maxillary artery) Disability face trauma = head trauma neck trauma Exposure 5

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ATLS Airway Breathing Circulation bleeding (maxillary artery) Disability face trauma = head trauma neck trauma Exposure ATLS Airway Breathing Circulation bleeding (maxillary artery) Disability face trauma = head trauma neck trauma Exposure ATLS Airway Breathing Circulation bleeding (maxillary artery) Disability face trauma = head trauma neck trauma Exposure 7

ATLS Airway Breathing Circulation bleeding (maxillary artery) Disability face trauma = head trauma neck trauma Exposure Occipital Condyle Ocular Injuries with Facial Trauma Al-Qurainy et al., 1991 63% Minor/transient chemosis, corneal abrasion 16% Moderate conjunctival laceration, lens damage 12% Severe retrobulbar hemorrage, hyphema optic nerve injury, visual field loss Ocular Injuries with Facial Trauma Al-Qurainy et al., 1991 63% Minor/transient chemosis, corneal abrasion 16% Moderate conjunctival laceration, lens damage 12% Severe retrobulbar hemorrage, hyphema optic nerve injury, visual field loss Visual Aquity Pupils Motilities Intraocular Pressure normal 10-20 mmhg Dilated Retinal Exam Slit Lamp Exam 8

Fractures Frontal Sinus Frontal Sinus Zygoma (ZMC) Orbital Floor Nasal Orbital Ethmoid Nasal Maxilla Mandible Anatomy- anterior/posterior table 800 2200lbs of force Middle Meatus/ Frontal Nasal Duct V1 Paresthesia/Anesthesia, Deformity Occular Symptoms CT, Ant/Post Tables, Other Injuries (70%) Globe Neurosurgery (40%) Ophthalmology Frontal Sinus Frontal Sinus Anatomy- anterior/posterior table 800 2200lbs of force Middle Meatus/ Frontal Nasal Duct V1 Paresthesia/Anesthesia, Deformity Occular Symptoms CT, Ant/Post Tables, Other Injuries (70%) Globe Neurosurgery (40%) Ophthalmology Anatomy- anterior/posterior table 800 2200lbs of force Middle Meatus/ Frontal Nasal Duct V1 Paresthesia/Anesthesia, Deformity Occular Symptoms CT, Ant/Post Tables, Other Injuries (70%) Globe Neurosurgery (40%) Ophthalmology 9

Frontal Sinus Frontal Sinus Anatomy- anterior/posterior table 800 2200lbs of force Middle Meatus/ Frontal Nasal Duct V1 Paresthesia/Anesthesia, Deformity Occular Symptoms CT, Ant/Post Tables, Other Injuries (70%) Globe Neurosurgery (40%) Ophthalmology Anatomy- anterior/posterior table 800 2200lbs of force Middle Meatus/ Frontal Nasal Duct V1 Paresthesia/Anesthesia, Deformity Occular Symptoms Admission/Antibiotics Out Patient Amoxicillen/Augmentin/Clindamycin Zygomatic Maxillary Complex Anatomy- aticulations: maxilla, frontal, sphenoid, temporal Zygomatic Maxillary Complex Anatomy- aticulations: maxilla, frontal, sphenoid, temporal 10

Zygomatic Maxillary Complex Zygomatic Maxillary Complex Peri orbital Ecchymosis/Edema Depressed Malar Eminence V2 Paresthesia Chemosis Subjunctival Hemorrhage Decreased Acuity Limited EOM Forced Duction Visual Acuity EOM Pupillary Exam Ophthalmologic Consultation Fundoscopic Exam Fine Cut CT Axial, Coronal, Sagital 3D Recon Zygomatic Maxillary Complex Zygomatic Maxillary Complex Visual Acuity EOM Pupillary Exam Ophthalmologic Consultation Fundoscopic Exam Fine Cut CT Axial, Coronal, Sagital 3D Recon Admission/Antibiotics Outpatient Amoxicillen/Augmentin/Clindamycin 11

Orbital Floor Orbital Floor Anatomy Etiologies Hydraulic Theory, Retropulsion Theory (Smith and Regan) Buckling Theory (Pure vrs. Impure) Orbital Floor Orbital Floor Decreased Visual Acuity Limited EOM/ Double Vision Forced Duction Chemosis Conjunctival Hemorrhage V2 Paresthesia Visual Acuity EOM Forced Duction Pupillary Exam Ophthalmologic Consultation Fundoscopic Exam Fine Cut CT Axial, Coronal, Sagital 12

Orbital Floor Orbital Floor Admission/Antibiotics Outpatient Amoxicillen/Augmentin/Clindamycin Admission Operating Room Orbital Floor Nasal Orbital Ethmoid Classification Admission Operating Room 13

Nasal Orbital Ethmoid Nasal Orbital Ethmoid Classification Periorbital Ecchymosis/edema Decreased Acuity Nasal Deformity Telecanthis Mobility of Nasal BonesDepression Nasal Radix Nasal Orbital Ethmoid Traumatic Telecanthis Normal Intercanthal Distance 30-32 mm Normal Interpupillary Distance 60-65mm Periorbital Ecchymosis/edema Decreased Acuity Nasal Deformity Telecanthis Mobility of Nasal Bones Depression Nasal Radix 14

Nasal Orbital Ethmoid More Severe Injuries Ruled Out Head CT, C-Spine Negative Visual Acuity, EOM, Pupil Exam Fundoscopic Exam Ophthalmology Consult Nasal Orbital Ethmoid Nasal Orbital Ethmoid More Severe Injuries Ruled Out Head CT, C-Spine Negative Admission/Antibiotics Admission for Other Injuries Visual Acuity, EOM, Pupil Exam Fundoscopic Exam Ophthalmology Consult Face CT (1mm) 15

Classification Classification Classification 16

Skeletal Mobility Widening/ Flattening Malocclussion Palatal/Mucosal Laceration Ecchymosis V2 Paresthesia Skeletal Mobility Widening/ Flattening Malocclussion Palatal/Mucosal Laceration Ecchymosis V2 Paresthesia Skeletal Mobility Widening/ Flattening Malocclussion Palatal/Mucosal Laceration Ecchymosis V2 Paresthesia Skeletal Mobility Widening/ Flattening Malocclussion Palatal/Mucosal Laceration Ecchymosis V2 Paresthesia 17

Level of Fracture Occlussion Globe Face CT Axial, Coronal Sagital 3D Level of Fracture Occlussion Globe Face CT Axial, Coronal Sagital 3D Mandible Admission/Antibiotics Admit Unasyn/Clindamycin Ellis,E et al. Ten Years of Mandibular Fractures: An Analysis of 2,137 Cases. Oral Surg Oral Med Oral Pathol 59(2) 1985. Data Collected from Canniesburn Hospital, Glasgow, Scotland. (Serves a Population of 3 Million) Mandible fractures represented 45% of all Facial Fractures Treated during a 10 year Period (1973-1983) 48% Single Fracture, 45% Two Fractures, 7% > 2 Fractures. 29% SubCondylar, 30% Angle, 32% Body, 9% Symph (PS) 18

Mandible Ellis,E et al. Ten Years of Mandibular Fractures: An Analysis of 2,137 Cases. Oral Surg Oral Med Oral Pathol 59(2) 1985. Data Collected from Canniesburn Hospital, Glasgow, Scotland. (Serves a Population of 3 Million) Mandible fractures represented 45% of all Facial Fractures Treated during a 10 year Period (1973-1983) 48% Single Fracture, 45% Two Fractures, 7% > 2 Fractures. 29% SubCondylar, 30% Angle, 32% Body, 9% Symph (PS) 19

Radiographic Evaluation Mandible Series PA, Lateral Obliques, Townes Panorex CT Coronal 3D Reconstruction 20

Mandible Airway Bleeding Diagnose all Fractures Mandible Admission/Antibiotics Admit Unasyn/Penn/Clindamycin 21