Facial Trauma
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http://decode-medicine.blogspot.com/ by sun yaicheng
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Facial Trauma
- 1. Facial Trauma http://decode-medicine.blogspot.com/ by sun yaicheng
- 6. Look at the orbits carefully, 60 - 70% of all facial fractures involve the orbit. Exceptions: local nasal bone fracture, zygomatic arch fracture, LeFort I fracture. Bilateral symmetry can be very helpful. Carefully trace along the lines of Dolan when examining the Waters view in a facial series.
- 8. Radiographic Signs of Facial Fractures Direct Signs nonanatomic linear lucencies cortical defect or diastatic suture bone fragments overlapping causing a "double- density" asymmetry of face Indirect Signs soft tissue swelling periorbital or intracranial air fluid in a paranasal sinus
- 9. Emergency Management and Resuscitation Airway Most urgent complicationl: Airway compromise Simple interventions first No mandible? Intubation Avoid nasotracheal intubation Aviod RSI Benzodiazepines Ketamine Etomidate Be Prepared and Be Creative
- 10. Emergency Management and Resuscitation Airway Management Options Awake intubation Fiberoptic intubation Lateral or semi-prone position Percutaneous transtracheal jet ventilation Retrograde intubation Cricothyroidotomy
- 11. Emergency Management and Resuscitation Hemorrhage Control Rarely develop shock from facial bleeding alone Direct Pressure LeFort Fractures Nasal hemorrhage may require A&P packing
- 12. Maxillofacial Trauma-History How is your vision? Is any part of your face numb? Are your teeth meeting normally?
- 13. Maxillofacial Trauma-Physical Exam Inspection Palpation Facial elongation Tenderness High grade LeFort (intraoral palpation) Fracture Step offs Asymmetry Facial stability Deformities and cranial nerve injury Crepitus Subcutaneous air Cutaneous anesthesia
- 14. Maxillofacial Trauma-Physical Exam Periorbital and Orbital Exam Perform early Professional Lid Retractor
- 15. Maxillofacial Trauma-Physical Exam Periorbital and Orbital Exam Look for exophthalmos or enophthalmos Pupil shape Hyphema Visual acuity Entrapment signs Raccoon sign Bimanual Palpation Test
- 16. Maxillofacial Trauma-Physical Exam Oral and Mandibular Exam Mandible deviation Teeth malocclusion Paresthesia Tongue Blade Test 95% Sensitive 65% Specific
- 17. Maxillofacial Trauma-Imaging PE detects up to 90% of fractures Plain Films: Waters CT Orbital fractures 3D images available
- 18. Maxillofacial Trauma-Specific Fractures Orbital Fractures Usually through floor or medial wall Enophthalmos Diplopia Infraorbital stepoff deformity Subcutaneous emphysema 24 % of fractures are “Blowout fracture” the arrows associated with ocular point to the fracture fragments and injury periorbital tissue which have herniated into the maxillary sinus
- 20. Maxillofacial Trauma-Specific Fractures Zygomatic Fractures Tripod fracture Most serious Lateral subconjunctival hemorrhage Need ORIF
- 21. Tripod Fracture
- 22. Maxillofacial Trauma-Specific Fractures Maxillary Fractures High-energy injury Malocclusion Facial lengthening CSF rhinorrhea Periorbital ecchymosis
- 23. Lefort Classification Weakest areas of midfacial complex when assaulted from a frontal direction at different levels (Rene’ Lefort, 1901) Lefort I: above the level of teeth Lefort II: at level of nasal bones Lefort III: at orbital level
- 24. LeFort Fractures
- 25. LeFort I Transmaxillary fracture runs between the maxillary floor and the orbital floor. It may involve the medial and lateral walls of the maxillary sinuses and invariably involves the pterygoid processes of the sphenoid. The floating fragment will be the lower maxilla with the maxillary teeth
- 26. LeFort II Occurs along yet another weak zone in the face, and is sometimes called a pyramidal fracture because of its shape.
- 27. LeFort III craniofacial disassociation large unstable (floating) fragment is virtually the entire face!
- 29. Mandibular Fractures Second most common facial fracture Often multiple Mal-occlusion Intra-oral lacerations Sublingual ecchymosis Nerve injury Plain films Panorex CT
- 30. Clinical Findings Facial distortion Malocclusion of the teeth Abnormal mobility of portions of the mandible or teeth
- 33. Nasal Bone Fracture Common pitfalls in viewing the nasal bone are the normal sutures lining the nasal bone CSF rhinorrhea Halo sign
- 35. 25男性業務員騎機車過馬路時，不慎和對方來車相撞， 119送他到醫院時，發現他下巴中間有凹陷，臉部和口 腔都在流血，右側脖子腫脹，血壓80/50 mmHg、心跳 120/min、呼吸32/min，下列何種醫囑要先執行？ A. 臉部和口腔壓迫止血 B. 下巴固定 C. 輸林格氏液2000ml D. 口咽氣管插管 E. 環甲軟骨切開術 （cricothyroidotomy） 96 急專
- 36. 一位20歲男性騎車被貨車壓過，到院時有頭部外傷，顏面 骨骨折出血，胸部及腹部鈍傷，右大腿變形，BP： 80/40mmHg，HR：140/min，左側呼吸音減弱，上腹部有 輪胎壓痕，下列何者為處理之順序？ a.頭部電腦斷層 b.腹部超音波 c. 環甲膜切開術(Cricothyroidotomy) d.左側胸管插入 e.大腿固定 A. c,a,b,d,e B. c,d,b,e,a C. a,d,c,b,e D. c,d,a,b,e 95 急專 E. c,d,b,a,e
- 37. 一個戽斗男在ㄧ陣大笑後，嘴巴張大卡住無法閉合， 診斷為顳下頜關節脫臼（temporo-mandibular joint dislocation），關於其處置何者為非？ A. 應對下頜骨照全口X光 (Panoramic view) 以排除骨 折通常為兩側一起脫臼 B. 如果單側脫臼，下頜骨會偏向患側之對側 C. 復位時醫師以雙手伸入患者口中握住下頜骨兩側， 其復位方向為向上向後（以病患為基準） D. 有可能反覆發作 95 急專
- 38. 70 歲婦人於打呵欠時，突然右側下巴轉角處（mandibular angle）劇烈疼痛，嘴巴無法完全閉合。X 光確定並無骨折存 在，此時最合適的處置為： A. 病人平躺面朝上，由正面按住病人兩側下巴轉角 （mandibular angle）往頭的方向推 B. 病人坐著，由後面按住病人下巴轉角後方，施力令病人的 頭部後仰（extension） C. 病人坐著，將手指伸入病人嘴巴，按住患側臼齒或前臼齒 處，往下及有點往後施力 D. 病人坐著，助手由後扶住病人頭部，面對病人將手指伸入 病人下顎門牙內側往前方拉 E. 姿勢不拘，施力於正常一側臉部下巴轉角處，往患側推 擠；若無效再試施力於患側臉部下巴轉角，往另一側推擠 98 急專
- 39. 25 歲男性，因右眼被打了一拳而至急診就診， 身體檢查發現，右眼無法往上看，同時有複視， 懷疑眼眶爆裂性骨折（orbital blowout fracture），你預期還有的身體檢查發現，不包 括下列何項？ A. 右側臉頰感覺異常 B. 眼球內陷 C. 眼眶周圍皮下氣腫 D. 結膜下出血 E. 腦脊髓液鼻漏 98 急專