ASSESSMENT OF TRAUMA

1. Good
Morning
Sohail’s photography…
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2. Seminar topic: Assessment of trauma
Presented by: Dr.Suhail
3rd year post graduate
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3. 1. Introduction
2. Epidemiology
3. Incidence
4. Etiology
5. Examination of facial trauma
6. Diagnosis
7. Initial approach to trauma
8. ATLS
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4. Definition:
 The Merriam Webster Dictionary defines trauma as an injury (as a wound) to living
tissue caused by an extrinsic agent
Trauma is the Greek word for "wound". Although the Greeks used the
term only for physical injuries, nowadays trauma is just as likely to
refer to emotional wounds.
4

5. Epidemiology:
• Trauma to the oral region - 5% of all injuries
• In preschool children- 18% of all injuries
• Amongst all facial injuries, dental injuries are the most common of
which crown fractures and luxations occur most frequently.
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6.  Trauma to the maxillofacial region mandates special attention.
 Important sensory systems are contained within the face
(e.g. vision, auditory, somatic sensation, gustatory, olfaction and vestibular).
 Also, vital structures in the head and neck region are intimately associated
(airway, blood vessels, nerves and gastrointestinal tracts).
 Lastly, the psychological impact of disfigurement can be devastating
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7. Incidence
• The greatest incidence of trauma to the primary dentition occurs at 2
to 3 years of age, when motor coordination is developing.
• The most common injuries to permanent teeth occur secondary to
falls, followed by traffic accidents, violence, and sports.
• All sporting activities have an associated risk of orofacial injuries due
to falls, collisions, and contact with hard surfaces
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8. Incidence according to location:
Middle 3rd fractures 4
Frontal and nasal bone 1
Palatal split 1
Zygoma,arch, NOE, & palatal split 1
D.A # of rt maxilla 1
Mandible 22
Symphysis 2
paraymphysis 12
Body 1
Condyle 1
parasymphysis&angle 3
Parasymphysis&body 2
Parasymphysis &condyl 1
8

9. • History of trauma in both primary and permanent teeth- 46% of
children
• Boys show more frequency than girls in permanent teeth, no
significant sex difference in primary teeth
• Peak incidence in boys- 2-4 year and 9-10 year. Girls- 2-3 years
• Facial injuries- common in boys of 6-12 yr of age, mandible is most
affected
• Teeth involved- 37% upper central incisor 18% lower central incisor
6% lower lateral incisor 3% upper lateral incisor
• Frequency increased with increase in over jet
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10. Predisposing Conditions:
• Facial profile: more common in, Angles class II type I malocclusion
• Cerebral palsy: due to, – abnormal muscle tone and function in oral
area producing protrusion of maxillary anterior teeth – Poor skeletal
and muscle co-ordination
• Epileptic patients
• Dentinogenesis imperfecta
10

11. Etiology:
• FALL: - Frequent during first year of life - peak incidence just before
school age
• BATTERED CHILD SYNDROME: - abused or neglected child who
have suffered serious physical abuse
• ACCIDENTS: - bicycle accidents, automobile accidents, play ground
accidents
• SPORTS: - sports like football, baseball, basketball, wrestling,
kabbadi,
11

12.  Severity of Injury
• Energy of impact
• Resiliency of the impacting object
• Shape of the impacting object
• Angle of direction of the impacting force
12

13.  Mechanism of dental trauma (Andreasen and Bennett)
 Direct trauma: occurs when the tooth itself is hit
 Indirect trauma: inflicted when lower dental arch is forcefully closed
against the upper
Direct trauma
Indirect trauma
13

14. With increasing age and facial growth, in a downward and forward direction, the midface
and mandible become more prominent and the incidence of facial fractures increases,
while cranial injuries decrease.
14
At birth, the ratio between cranial volume and facial volume is approximately
8:1. By the completion of growth, this ratio becomes 2.5:1.
The retruded position of the face relative to the ‘‘protecting’’ skull is an important reason for
the lower incidence of midface and mandibular fractures and higher incidence of cranial
injuries in young children (less than 5 years of age).

15.  A childs facial skeleton differs from that of an adult in that the mandible is more
developed than the middle 3rd of face .
 The anatomic and developmental factors like elastic bones ,thin cortical plates
,presence of developing tooth buds within the bone ,developing paranasal sinuses
contribute to decreased incidence of fractures of facial skeleton.
 Because of high osteogenic potential of periosteum ,there is early union of
fractures hence it is important that fractures in children have to diagnosed and
treated at an early stage .
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16. Classification : Based on extent
 Simple/Closed–does not produce wound to external environment.
 Compound/Open–external wound communicates with the fracture.
 Comminuted–bone is splintered/crushed
 Greenstick–one cortex of bone is fractures and the other is bent.
 Pathologic–due to pre-existing bone disease
 Multiple–>2fracture lines that do not communicate.
 Impacted–one fragment driven firmly into the other.
 Atrophic–due to severe atrophy e.g. edentulous.
 Indirect–distant from site of injury
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17. Team for Maxillofacial trauma care 17

18. OPTHALMOLOGIST:
Impaired vision.
Eyeball or large eyelid laceration.
Direct eye ball trauma.
Amnesia.
Comminuted mid face trauma.
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19. EAR, NOSE, THROAT SURGEON:
Post traumatic hearing problems.
Large defects in external ear.
Vertigo.
NEUROSURGEON:
Intra cranial problem.
CSF otorrhea/rhinorhea.
19

20. Chief Complaint:
• The chief complaint may include several subjective symptoms.
• These should be listed in order of importance to the patient.
• Also note the duration of each symptom.
 History of Present Illness (Injury)
• Obtain information about the accident in chronologic order – Date, –
time, – place, – how the injury took place
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21.  Has the patient noticed any other symptoms after injury
• Signs and symptoms to watch for are dizziness; vomiting; severe
headaches; seizures or convulsions; blurred vision; unconsciousness;
loss of smell, taste, hearing, sight, or balance; or bleeding from the nose
or ears.
• Affirmative response to any of the above indicates the need for
emergency medical evaluation.
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22. Questionaire:
 Note any treatment before this examination
 Question the patient about previous injuries involving the same area.
 Specific problems with the traumatized tooth/teeth
 Pain, mobility, and occlusal interference are the most commonly
reported symptoms.
 In addition, the patient should be asked about any symptoms from
adjacent soft tissues such as tongue, lips, cheeks, gingiva, and
alveolar mucosa.
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23. History:
 A detailed history is important when the patient is first seen after an
injury.
 Questions should be asked to determine – the cause of the injury, –
symptoms, – possibility of concomitant injuries, and – the medical
history of the patient before an accurate diagnosis and treatment plan
can be established.
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24. EYE WITNESS REPORTS OF INCIDENT:
H/O consciousness,
H/O bleeding.
24

25. Medical History:
 Allergies
 Disorders such as bleeding problems, epilepsy, diabetes.
 Current medications.
 Tetanus immunization status – For clean wounds, no booster dose is
needed if no more than 10 years have elapsed since the last dose. –
For contaminated wounds, a booster dose should be given if more
than 5 years have elapsed since the last dose.
25

26. EXAMINATION:
 A thorough history and examination are necessary of the patient who has suffered
dental-trauma.
• Findings should be documented in the records
26

27. Clinical Examination:
• A careful, methodical approach to the clinical examination will reduce
the possibility of overlooking or missing important details.
 Hemorrhage , Otorrhea ,Rhinorrhea, Contour deformity,
Ecchymosis , Edema. Discontinuity, Malocclusion
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28. Examination of Soft tissues:
• All areas of soft tissue injury should be noted, and the lips, cheeks, and
tongue adjacent to any fractured teeth should be carefully examined and
palpated.
• It is not unusual for tooth fragments to be buried in the lips.
• The radiographic examination should include specific exposures of the lips
and cheeks if lacerations and fractured teeth are present – rule out foreign
objects.
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29. Lip injuries
 Inspect the lips carefully.
 Any disruption of the vermilion border should be noted; failure to do
so can lead to inadequate repair, which can result in significant
cosmetic deformity
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30. Tongue injuries
 When examining the injured tongue, note the depth and length of the
injury as well as the absence of any tissue.
 Many minor lacerations do not require repair.
 Complex injuries such as through-and-through lacerations may be
associated with foreign bodies and can result in a bifid tongue if not
properly repaired
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31. Hard and soft palate injuries 31
• The most common objects causing impalement injuries in children are
sticks, pens/pencils, cylindrical toys, and straws.
• Extent of trauma has to be assessed

32. Frontal bone fractures:
 Usually result from a high velocity blunt trauma to the forehead (e.g.
MVA).
 The anterior and/or posterior table of the frontal sinus may be
involved.
 More than one-third of patients with frontal sinus fractures are likely
to have concomitant intracranial injury
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33. Should start from scalp:
 Start the maxillofacial examination by inspecting the scalp and
cranium
 To avoid missing any scalp injuries, examine patients thoroughly
during the secondary survey.
 After cleaning the wound, attempt hemostasis with direct pressure.
 Examine the areas around any lacerations for bony step-off that
would indicate a possible underlying skull fracture
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34. Skull:
 Examination should commence with an inspection of the scalp for
contusions and lacerations concealed by the hair; particular attention
should be paid to the back of the head where such injuries may be
overlooked.
 Palpation to find any tenderness, crepitation, depressed or
penetrating bone fragments or contour irregularities.
 Document any asymmetries, deformities, swellings or hematomas.
34

35. EXAMINATION OF EAR:
Check the external ear for laceration, any hematomas and
defects that might need evacuation with surgical procedure.
An obstruction, hematoma or laceration in the wall of the
canal might indicate a fracture of the temporomandibular joint
fossa and posterior dislocation of condylar head.
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36. Weber and Rinne test- tuning fork – middle and inner ear
36

37. Clean the auditory canal of blood to enable adequate identification of
the bleeding site and to examine the tympanic membrane and observe
blood in the middle ear which suggests a skull base fracture.
Sometimes cerebrospinal fluid leakage also can be observed usually
mixed with blood in case of a ruptured tympanic membrane.
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38. EXAMINATION OF EYE:
According to Al-Qurainy .et al. 63% of patients who had
midfacial fractures also had minor or transient ocular injuries
– 12% sever ocular injuries.
Tetrapod fractures with or without distracted FZ suture were
the most common cause of mild ocular injuries.
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39. MAXILLOFACIAL SURGERY, WARD BOOTH, SECOND EDITION, 2007
Significant periorbital echymosis and swelling impair the
examination of the eyes but this must never be an excuse for not
performing test.
OPTHALAMIC DATA:
Visual acuity and perception of light use a standard chart if
possible, if not, use available text and at least establish the ability to
count fingers.
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40. Position of the eye, pupillary levels and enoptholmous and
proptosis.
Conjunctival-edema, haemorrahage and pupils- symmetry and
reaction.
OCULAR MOTILITY DATA:
Diplopia or history of transient diplopia.
Pain on eye movement, restriction of extra ocular movements.
Manifest deviation of the eye in the primary gaze position
40

41. Orbital floor fractures:
 Injury to the orbital floor can result in an isolated fracture or can be
accompanied by a medial wall fracture.
 Most injuries are associated with traumatic injury through
interpersonal violence, sport or road-traffic collision
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42. Nasoethmoidal fractures:
 Because of the prominence of the nose and its central location on the
face, nasal fractures are the most common facial fracture.
 Due to the degree of force and the vectors involved, NOE fractures
rarely occur as isolated events.
 Associated injures often include cribriform plate fracture,
cerebrospinal fluid rhinorrhea, and fractures of the frontal bone,
orbital floor, and middle third of the face, as well as injury to the
lacrimal system
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43. EXAMINATION OF THE NOSE:
Palpation usually shows motility or crackling if fractures are
present.
Deviation usually can appreciated by examination and
palpation.
Examination of the airway is certainly important in acute
phase and internal examination of the nose is deviated to the
septum to identify hematoma.
An over looked septal hematoma in children can lead to later
deformity. We should treat aggressively if septal hematoma
noted.
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44. CSF LEAKAGE: is important and suggests a more severe NOE and
maxillary fracture extending through the cribriform plate.
Approximately 20% of skull base fractures will develop a CSF leak
manifested as rhinorhea or otorrhea.
These are the result of a tear of the dura and arachnoid at the skull
base.
Resolves spontaneously within 1 week in 70%of patients and, in 80%,
they heal by 6 months.
To facilitate the diagnosis of CSF leak, a few drops of the fluid can be
placed on a tissue
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45. NOE COMPLEX FRACTURES:
INSPECTION:
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46. 46
In children
40 – 45 mm
In children
22 – 30 mm

47. ORALAND MAXILLOFACIAL TRUAMA, 4 TH EDITION, FONSECA, 2013.
Bimanual palpation test
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48. ORAL AND MAXILLOFACIAL TRUAMA, 4 TH EDITION, FONSECA, 2013.
The bowstring test:
Performed by gently holding the NOE complex ( in a
manner similar to that described earlier) and pulling the lateral
canthal tendon laterally.
When a fracture is present, the examiner will be able to
defect movement of the medial canthal and any detached bone
fragments.
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49. Zygomaticomaxillary complex fractures (ZMC):
 These fractures result from direct trauma.
 Fracture lines extend through zygomaticotemporal, zygomaticofrontal, and
zygomaticomaxillary sutures and the articulation with the greater wing of
the sphenoid bone.
 The majority of these fractures result from trauma inflicted in altercations
followed by MVA
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50.  The most common problems associated with zygomatic complex fractures
include: facial asymmetry, enophthalmos, anesthesia or paresthesia in the
distribution of the infraorbital nerve (V2), orbital floor defects with entrapment
of orbital soft tissues with or without limitation of eye movement.
Zygomaticomaxillary complex fractures
(ZMC):
50

51. MAXILLARYAND MID FACIAL FRACTURES
CHEK FOR CONTINUTY AND TENDERNESS IN THE FACIAL REGION:
Frontal bone
Supra orbital rim
Glabella ( fronto nasal suture)
FZ suture
Lateral orbital rim
Orbital floor
Malar bone prominence
Zygomatic arch continuity
Nasal bone
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52. Mid face fracture:
 These are classified as Le Fort I, II, or III.
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53. Le fort 1 :
 The Le Fort type I fracture pattern results from a force directed above the
maxillary teeth, resulting in a floating palate.
 The fracture occurs at the level of the piriform aperture and involves the anterior
and lateral walls of the maxillary sinus, lateral nasal walls and, by definition,
pterygoid plates.
 The nasal septum may also be fractured and the nasal cartilage may be buckled.
Sagittal fracture(s) of the palate may also be present.
 This fracture may present as an impacted, immovable, or free-floating maxillary
segment.
53

54. CRANIOMAXILLOFACIAL TRAUMA, SIMPSON, 1996.
54

55. A). LE FORT I/ FLOATING FRACTURE/ GUERIN FRACTURE/ LOW LEVEL
FRACTURE/ SUBZYGOMATIC FRACTURE
1. MOBILITY OF MAXILLARY ALVEOLAR SEGMENT (FLOATING
FRACTURE)
2. PAIN AND TENDERNESS WHILE SPEAKING OR CLENCHING
3. ECCHYMOSIS OR LACERATION IN LABIAL OR BUCCAL VESTIBULE
4. ECCHYMOSIS AT GP FORAMEN (GUERIN SIGN)
5. SWELLING AND OEDEMA OF UPPER LIP
6. MAL OCCLUSION
7. BILATERAL EPISTAXIS
8. BRUISING OF PALATAL TISSUES (15-20% OF CASES)
9. ON PALPATION TENDERNESS OVER BUTTRESS AREA
10. PERCUSSION OF TEETH – CRACKED POT SOUND
Clinical Features 55
Guerin sign

56. Le fort ii :
 The Le Fort type II fracture pattern is also referred to as a pyramidal fracture; the
apex of the pyramid is the nasofrontal suture.
 This fracture pattern involves the nasofrontal suture, nasal and lacrimal bones,
infraorbital rim in the region of the zygomaticomaxillary suture, maxilla, and
pterygoid plates.
 This fracture is typically higher than the Le Fort type I fracture posteriorly. As
with the Le Fort type I pattern, the nasal septum may also be involved.
56

57. CRANIOMAXILLOFACIAL TRAUMA, SIMPSON, 1996.
57

58. B). Le fort II/ Pyramidal fracture/ Mid level fracture/ Subzygomatic
fracture
1. Oedema mid third of face (Moon face)
2. Paresthesia of cheek
3. Bilateral circumorbital ecchymosis
4. Bilateral subconjunctival haemorrhage
5. Dish face deformity
6. Depressed nose
7. Epistaxis
8. CSF rhinorrhea
9. Limited ocular movement (Diplopia)
10. Mal occlusion
11. Inability to open mouth
12. Step deformity at IO margins
13. Mobility of fractured fragment at nasal bridge and IO margins
14. Percussion of teeth – cracked pot sound
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59. MAXILLOFACIAL SURGERY, WARD BOOTH, SECOND
EDITION, 2007
59

60. Le fort iii :
 craniofacial dysjunctions
 Anteriorly: nasofrontal and frontomaxillary sutures and extend posteriorly along
the medial wall of the orbit through the nasolacrimal groove and ethmoid bones.
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61. C). Le fort III/ Craniofacial dysfunction/ High level fracture/
Suprazygomatic fracture
1. Oedema of face (Panda facies)
2. Bilateral periorbital edema
3. Bilateral circumorbital ecchymosis (Racoon eyes)
4. Bilateral subconjunctival haemorrhage
5. Dish face deformity
6. Depressed nose, flattening of nose
7. Epistaxis
8. CSF rhinorrhea
9. Limited ocular movement (Diplopia, Enophthalmos)
10. Dystopia, hooding of eyes with antimongloid slant
11. Haemotympanum
12. CSF otorrhoea
13. Mal occlusion – posterior gagging of occlusion
14. Inability to open mouth
15. Mobility of fractured fragment at NF, FZ sutures
16. Tenderness over zygomatic bone, arch and FZ suture
17. Ecchymosis at mastoid process (Battle’s sign)
61

62. 62

63. Mandibular fractures:
 These can occur in multiple locations secondary to the U-shape of
the jaw and the weak condylar neck.
 Fractures occur secondary to direct or indirect facial injury,
including MVA, sports, and assaults with blunt objects.
 Close to half of all patients with maxillofacial injuries have
concomitant mandibular fractures
63

64. Pediatric Mandible Fractures
 Incidence of fractures in children under 15 years- 0.31/100,000
 Usually represent less than 10% of all mandible fractures for
children 12 years or younger
 Less than 5% of all mandible fractures for children 6 years or
younger
64

65. 65

66. Pediatric Mandible Fractures
 Uniqueness of children:
 Nonunion and fibrous union are rare due to osteogenic potential
of children. They heal rapidly.
 Due to growth, imperfect fracture reduction can be “compensated
with growth”. Therefore, malocclusion and malunions usually
resolve with time.
66

67. Pediatric Mandible Fractures
 Uniqueness of children:
 The mandible tends to be thinner and has a less dense cortex
 Presence of tooth buds in the lower portions of the mandible.
 Short and less bulbous deciduous teeth make arch bar application difficult
67

68. Based on anatomical location 68
Symphysis–region of central incisors through to inferior border
of mandible.
Parasymphyseal–vertical and distal to the canines.Body–from distal symphysis alveolar border of masseter
muscle.
Angle–Triangular region bounded by masseter muscle.Ramus–superior to the angle with apex at sigmoid notch.Coronoid –fracture of coronoid process.Alveolar–region usually containing teeth.Condylar.

69. CRANIOMAXILLOFACIAL TRAUMA, SIMPSON, 1996.
69Palpating the mandible

70. MAXILLOFACIAL SURGERY, WARD BOOTH, SECOND EDITION, 2007
70

71. Physical exam:
 Edema- non descript
 Abrasions/lacerations- potential for compound fracture
 Ecchymosis- especially floor of mouth
 Symphyseal or body fracture
 Crepitus with manipulation
 Altered sensation/parathesia
 Dolor/Tumor/Rubor- signs of inflammation
71

72. Malocclusion
Anterior open bite- bilateral condylar or angle
Unilateral open bite- ipsilateral angle and parasymphyseal
fracture
Posterior cross bite- symphyseal and condylar fractures with
splaying of the posterior segments
Prognathic bite- TMJ effusions
Retrognathic bite- condylar or angle fractures
72

73. Condylar fracture 73

74.  New borns – head projects
posteriorly, has flat surface
 Highest peak point is in the
center – at mixed dentition
 Moves laterally 1/3rd at
permanent dentition
 The cartilage slowly changes to
fibrocartilage as the age
progresses
74

75. Classification
Based on Anatomical location
 Type I - Intra capsular fracture
75

76. Type II- Fracture of condylar neck 76

77. Type III - Subcondylar fracture 77

78.  Type IV, low condylar neck fracture with dislocation i.e. luxation
 Type V, High condylar neck fracture with dislocation
78

79. Pathophysiology of condylar injuries
 The nature of the condylar injuries and healing potential varies according to the
age of the patient.
 Three age groups have been identified.
79

80. youngest age group (0-2 year olds)
 In the youngest age group (0-2 year olds) the condylar neck is short and thick and
engages a shallow glenoid fossa.
80

81. Median age group (3-12 year olds)
 In the median age group (3-12 year olds) a more adult like configuration of the
condylar process and glenoid fossa develops, although unlike adults, there still
remains an enormous potential for regeneration and remodelling in this age group.
81

82. older age group (13-18 year olds) 82

83. 83

84. Clinical clues
 Contusions over the chin or preauricular area, and malocclusion are
all potential signs of a condylar or subcondylar fracture.
 Less commonly, a facial nerve deficit may be associated with an
injury to this area.
84

85. TMJ Dislocation 85

86. Palpation of TMJ 86

87. CT of TMJ: 87

88. Panfacial fractures:
 These usually are secondary to a high-energy mechanism resulting
in injury to the upper face, midface, and lower face.
 These fractures must be composed of at least 3 of the possible 4
facial units in order to be labeled panfacial.
88

89. Alveolar fractures:
 These can occur in isolation from a direct low-energy force or can
result from extension of the fracture line through the alveolar portion
of the maxilla or mandible
89

90. Examination of teeth:
• The teeth must be examined for fractures, mobility, displacement,
injury to periodontal ligament and alveolus, and pulpal trauma.
 Remember to examine the teeth in the opposite arch also. They, too,
may have been involved to some degree.
90

91. Mobility:
• Examine the teeth for mobility in all directions.
• If adjacent teeth move along with the tooth being tested, suspect alveolar fracture.
• Root fractures often result in crown mobility, the degree depending on the proximity
of the fracture to the crown.
• The degree of mobility can be recorded as follows: – 0 for no mobility, – 1 for slight
mobility, – 2 for marked mobility, and – 3 for mobility and depressibility.
91

92. Diagnosis
 Radiographic Evaluation
 Panoramic radiograph:
 Most informative radiographic tool
 Shows entire mandible and direction of fracture (horizontal favorable, unfavorable)
 Disadvantages:
 Patient must sit up-right
 Difficult to determine buccal/lingual bone and medial condylar displacement
 Some detail is lost/blurred in the symphysis, TMJ and dentoalveolar regions
92

93. Diagnosis
 This Towne’s view show a body fracture that is
displaced in a medial to lateral direction and a
subcondylar fracture with lateral displacement
93

94. Diagnosis
 Radiographic Evaluation
 Reverse Towne’s radiograph:
 Ideal for showing lateral or medial condylar displacement
94

95. Diagnosis
 Radiographic Evaluation
Lateral oblique radiograph:
Used to visualize ramus, angle, and
body fractures
Easy to do
Disadvantage:
 Limited visualization of the condylar
region, symphysis, and body anterior to
the premolars
95

96. Diagnosis
 Radiographic Evaluation
Posteroanterior (PA) radiograph:
Shows displacement of fractures in the ramus,
angle, body, and symphysis region
Disadvantage:
 Cannot visualize the condylar region
96

97. Diagnosis
 Radiographic Evaluation
 Occlusal views:
 Used to visualize fractures in the body in regards to medial or lateral
displacement
 Used to visualize symphyseal fractures for anterior and posterior
displacement
97

98. Diagnosis
 Radiographic Evaluation
 Computed tomography CT:
 Excellent for showing intracapsular condyle fractures
 Can get axial and coronal views, 3-D reconstructions
 Disadvantage:
 Expensive
 Larger dose of radiation exposure compared to plain film
 Difficult to evaluate direction of fracture from individual slices
(reformatting to 3-D overcomes this)
98

99. Diagnosis 99

100.  The size of the pulp chamber and the root canal, the apical root development, and
the appearance of the periodontal ligament space may all be evaluated by intraoral
radiographs.
 Changes in the pulp space, both resorptive and calcific, may suggest pulp
degeneration and indicate therapeutic intervention.
 Other radiographic views may be indicated in more extensive injuries than those
confined to the dentition.
 Finally, it is also important to carefully file all radiographs for future references
and comparisons.
100

101. GOLDEN HOUR
 The first hour following a trauma during which aggressive resuscitation can
improve the chances of survival and restore the normal functions.
 Early pre-hospital care, early transport, aggressive resuscitation and
interventions in ED, continued care in ICU have a definite and significant role
in preventing deaths due to trauma.
101

102. INITIALAPPROACH TO TRAUMA CARE
 Process that consists of
-Initial primary assessment
-Rapid resuscitation
-A more thorough secondary assessment
-Followed by diagnostic tests and disposition.
102

103. PRE-HOSPITAL INFORMATION AND
HANDOVER
M-I-S-T
 MECHANISM OF INJURY
 INJURIES SUSTAINED OR SUSPECTED
 SIGNS- VITALS ON SCENE AND DURING TRANSPORT
 TREATMENT INITIATED
103

104. Pediatric age groups:
 Same Priorities and Approach
 Need for different amounts of fluids and medications
 Need for equipment of varying sizes
104

105.  Children have a higher surface-to-body volume ratio, metabolic rate, oxygen demand and
cardiac output than adults.
105
• They also have lower total blood and stroke volumes than adults. Therefore, the risk for
hypothermia, hypotension and hypoxia after blood loss is higher in paediatric patients.
• Even mild airway swelling or mechanical airway obstruction can quickly compromise the
airway. For these reasons, maintenance of the airway and breathing, control of hemorrhage
and early resuscitation are even more critical and time dependent in children than in adults.

106.  Dental injuries could have improved outcomes if the public were
aware of first-aid measures and the need to seek immediate
treatment.
 Because optimal treatment results follow immediate assessment and
care, dentists have an ethical obligation to ensure that reasonable
arrangements for emergency dental care are available.
106

107. 107

108. Maxillofacial trauma &
esthetic facial reconstruction
peter ward booth , 11th edition
INITIAL ASSESSMENT 108

109. 109

110. ATLS way of trauma management
 Preparation
 Triage
 Primary survey (ABCDEs)
 Resuscitation
 Adjuncts to primary survey and resuscitation
 Secondary survey
 Adjuncts to secondary survey
 Continuous post resuscitation monitoring and re
evaluation
 Definitive care
110

111. Preparation
 Take universal precautions
 Check the availability of medicines and
functioning of equipments
 Designate the role to each team member
 Utilize pre hospital information
111

112. Initial assessment
 Primary survey – Evaluates physiology
 Secondary Survey – Evaluates anatomy
112

113. Primary survey
Primary survey and resuscitation of vital
functions are done simultaneously using a team approach
113

114. Primary Survey – ATLS way
 Airway with c-spine protection
 Breathing and ventilation
 Circulation with hemorrhage control
 Disability: Neuro status
 Exposure with environmental control
114

115. Primary Survey
Always consider physiological
variations in special populations
● Elderly
● Infants and Children
● Pregnant Women
● Obese
● Athletes
115

116. Quick Assesment
What is a quick, simple way to assess a
patient in 10 seconds?
Ask the patient his or her name?
Ask the patient what happened?
116

117. Appropriate Response confirms
1 – Patent airway
2 – Sufficient air reserve to permit speech
3 – Sufficient perfusion
4 – Clear sensorium
117

118. Primary survey
Airway – Establish patent airway with c-spine protection
Clear the airway using wide bore suction
Chin lift / Jaw thrust manoeuvre
Oropharyngeal / nasopharyngeal airway
Definitive airway
(Cuffed, Secured endotracheal tube)
Surgical airway
118

119. 119

120. Primary Survey
Breathing and ventilation – assess and ensure adequate
oxygenation and ventilation
120

121. Breathing and Ventilation
Assess
Jugular venous distension
Position of trachea
Respiratory rate
Percussion findings of chest
Air entry
Oxygen saturation
121

122. Breathing and ventilation
Recognise and treat early –
Tension pneumothorax
 Flail chest with pulmonary contusion
Massive haemothorax
Open pneumothorax
Immediate Chest decompression with
Oxygen delivery
122

123. LeFort I fracture
LeFort I fracture with Mandible fracture
LeFort I fracture with Nasal injury
LeFort II fracture
Lefort III fracture
Panfacial fractures
Nasal Airway
Edentulous Partially Dentate
with space
Fully Dentate
Oral Airway
through portal cut
in Gunning
splints or
dentures
Oral Airway
with tube
displaced through
space
Surgical
Airway
Guided Nasal
Intubation
• fixate maxilla
and mandible
• switch to Oral
Airway for
nasal/NOE
reduction
123

124. Hemorrhage in facial trauma
 Profuse bleeding can be from partially transected veins or arteries
 Bleeding can come from deep tissues, sinus lining
 Avoid blindly applying clamps as this can result in facial nerve
paralysis
 For uncontrollable bleeding: – Reduction of fractures (or facial
compression dressing) – Nasal packing – Embolization – External
carotid ligation
124

125. Circulation with haemorrhage control
Look for blood loss
 External bleeding
 Internal bleeding
• Chest
• Abdomen / Retroperitoneum
• Pelvis
• Long bones
One on floor four more
125

126. Circulation with haemorrhage control
Assess for organ perfusion
● Level of consciousness
● Skin color and temperature
● Pulse rate and character
126

127. Primary Survey
Circulatory Management
● Control hemorrhage
● Restore volume
● Reassess patient
Pitfalls
● Elderly
● Children
● Athletes
● Medications
127

128. D- Disability : Neurologic status
Rapid neurological examination is done for -
- Level of consciousness (GCS)
- Pupillary size and reaction
- Localizing signs
128

129. Primary survey - E
Expose the patient
Prevent hypothermia
Covering the patient
129

130. Prevention of aspiration
 Aspiration can occur in maxillofacial trauma
 Associated brain injury can depress LOC
 Aspirated material can be blood, gastric contents, teeth
 If there is a concern, prevention is by endotracheal intubation
130

131. Adjuncts to Primary Survey
PRIMARY SURVEY
ABGs
Urinary / gastric catheters
unless contraindicated
Urinary
output
ECG Vital signs
Pulse
oximeter
and CO2
131

132. When compared to adults, the pattern of fractures and frequency of associated
injuries are similar but the overall incidence is much lower.
Diagnosis is more difficult than in adults and fractures are easily overlooked.
Clinical diagnosis is best confirmed by computed tomographic (CT) scans.
Treatment is usually performed without delay and can be limited to observation or
closed reduction in non-displaced or minimally displaced fractures.
132

133. Operative management should involve minimal manipulation and may be modified by the stage
of skeletal and dental development.
Open reduction and rigid internal fixation is indicated for severely displaced fractures.
Primary bone grafting is preferred over secondary reconstruction and alloplastic materials should
be avoided when possible.
Children require long-term follow-up to monitor potential growth abnormalities.
This article is a review of the epidemiology, diagnosis and management of facial fractures in
children.
133

134.  Management of paediatric patient is a challenging task to the maxillofacial
surgeon
 A surgeon should have thorough knowledge of anatomy and physiology of a
growing child
 Any surgical procedure should be psychologically benefitting to child & parent
and do not leave any adverse effect on the future growth pattern of the child
134

135.  The overall facial fractures in the paediatric population comprise of less than 15
% of all fractures .
 Conservative management by closed reduction is best technique ,and considered
highly successful with negligible post operative complications.
135

136.  Treatment is usually performed without delay and can be limited to observation
or closed reduction in non-displaced or minimally displaced fractures.
 Operative management should involve minimal manipulation and may be
modified by the stage of skeletal and dental development. Open reduction and
rigid internal fixation is indicated for severely displaced fractures.
 Primary bone grafting is preferred over secondary reconstruction and
alloplastic materials should be avoided when possible.
136

137. References:
1. MAXILLOFACIAL SURGERY, WARD BOOTH,
SECOND EDITION, 2007
2. ORAL AND MAXILLOFACIAL TRUAMA, 4 TH
EDITION, FONSECA, 2013.
3. CRANIOMAXILLOFACIAL TRAUMA, SIMPSON,
1996.
4. MAXILLOFACIAL TRUMA, Ward booth, second edition,
2013.
5. Maxillofacial injuries-2nd edition, ROWE and
WILLIAMS, 2009.
6. Craniomaxillofacial trauma, Simpson, 1995