Mandibular Fracture

  • Mandibular fractures account for 10-25% of facial fractures.
  • Over half of patients with mandible fractures have fractures at more than one site on the mandible.
  • The mechanism of injury is often due to falls or altercations.
  • On physical examination assess the patient for pain with jaw movement, normal teeth approximation, external or intraoral lacerations, ecchymosis under the tongue, trismus, numbness of the lower lip or positive tongue blade test.
  • The tongue blade test is performed by having the patient bite down on a tongue blade. The physician then tries twisting the tongue blade in an attempt to break it. A patient with a mandibular fracture will immediately open their mouth when you try to twist the blade. This constitutes a positive tongue blade test.
  • Plain films (panorama view) should be obtained in patients with positive findings on physical examination or in those with a high index of suspicion for mandibular fracture.
  • In patients with negative radiographs but high clinical suspicion, a CT scan should be considered and is especially useful for diagnosing condylar fractures.
  • Patients with missing teeth should also receive a chest X-ray to exclude aspiration.
  • Definitive treatment includes immobilization and establishing proper occlusion using open or closed reduction.
  • These fractures are often contaminated with oral flora and patients should be treated with prophylactic antibiotics (penicillin G or clindamycin if pen-allergic) and tetanus immunization.

Zygomatic Fracture

  • Arch-Fractures of the arch often occur at multiple sites.
  • Patients may present with a variety of symptoms including trismus (due to impingement of the temporal is muscle or masseter muscle injury) or cheek pain.
  • Depression of the malar eminence can also be seen although edema can often mask this finding.
  • Tripod-A tripod fracture is the most common zygoma fracture and is found along three margins: the zygomaticofrontal suture, the zygomaticomaxillary suture, and the zygomatic arch.
  • This type of injury occurs as a result of a direct blow to the cheek often extending through the orbital floor. Sensory deficits are common and include anesthesia or paresthesia of the anterior cheek, upper lip, or lateral aspect of the nose due to infraorbital nerve involvement.
  • Marked periorbital edema and ecchymosis, loss of cheek prominence and subconjunctival and scleral hemorrhages are common findings of tripod fractures. With inferior displacement of the zygoma, depression of the lateral canthus may be noted.
  • Body-Fractures of the body result from extreme force.
  • This type of fracture clinically mimics tripod fractures and has many of the same signs and symptoms as noted above.
  • Radiologic Evaluation
  • Thin section axial and coronal CT scan has become the gold standard for evaluating zygomatic injuries. In facilities without CT scanning ability, plain films may be obtained.
  • For suspected arch fractures the underexposed sub mental view (bucket handle view) is best.
  • Tripod fractures can be evaluated with the Waters view which allows visualization of the inferior orbital rims, maxillary sinus, and the maxillary portion of the zygoma.

Frontal Sinus/Bone Fractures

  • Frontal sinus fractures are the third most common facial fracture and can occur due to trauma.
  • The clinical presentation is varied and can include:
  • Edema and/or hematoma of the glabellar region
  • CSF rhinorrhea (due to posterior wall fracture of the frontal sinus with dural penetration)
  • Supraorbital region depression
  • Lacerations
  • Supraorbital and/or supratrochlear nerve involvement
  • Down and forward globe proptosis
  • The imaging technique of choice to evaluate this type of injury is thin section axial and coronal CT scan.
  • An intracranial pneumocele is evidence of dural violation and neurosurgical consultation should be obtained.
  • Treatment for this type of injury ranges from observation to open reduction (e.g., nasofrontal duct involvement or displaced fractures) (Table 16.4).

Orbital Fractures

  • The maxilla and ethmoid bone comprise the inferomedial aspect of the orbit. This region is often the weakest and thus most prone to orbital blow-out fractures.
  • Approximately one-third of orbital blow-out fractures have an associated eye injury.
  • The imaging technique of choice is an orbital CT scan.

Maxillary Fractures

  • LeFort I-The fracture line extends horizontally above the teeth separating the lower maxilla from the upper face. The fracture line typically transects the maxillary sinuses.
  • This type of fracture does not typically cause hypesthesia since the fracture line is well below the infraorbital nerve.
  • Physical examination findings often include: facial swelling, mobile hard palate, epistaxis, fractured/avulsed teeth or malocclusion.
  • LeFort II (nasomaxillary fracture)-The fracture line separates the nasomaxillary complex from the upper face and passes through the lacrimal bones, inferomedial orbital walls, and posterolateral maxillary sinuses.
  • This type of fracture often extends through the zygoma; hypesthesia is common due to infraorbital nerve involvement.
    Table Management of frontal sinus fractures
    Fracture Disposition Treatment Required
    Nondisplaced
    anterior wall fracture    		 Discharge (Follow-up in 1-2
    wk for surgical evaluation and
    repeat films)    		 1. ANTIBIOTICS
    2. avoid valsalva maneuvers
    or further trauma
    Displaced anterior
    wall or sinus floor
    fracture    		 Admission 1. ANTIBIOTICS
    2. surgical evaluation
    exploration
    Posterior wall
    fractures    		 ADMISSION 1. ANTIBIOTICS
    2. immediate neurosurgical
    evaluation
    Maxillary fracture
    (inferior wall)    		 Inferior rectus muscle
    entrapment    		 Upward gaze dysfunction
    Ethmoid fracture
    (medial wall)    		 Medial rectus muscle
    entrapment    		 Lateral gaze dysfunction

  • Physical examination findings may include: facial edema, telecanthus (>45 mm), epistaxis, bilateral subconjunctival hemorrhages or CSF rhinorrhea.
  • LeFort III-This fracture results in craniofacial separation extending through the nasofrontal and frontomaxillary sutures including a fracture line through the floor of the orbits.
  • Physical examination findings often include: “dishface” deformity (face appears elongated and flattened), anterior open bite (due to posterior maxillary displacement) or CSF rhinorrhea.
  • All LeFort fractures commonly have blood in the maxillary sinuses.
  • Radiologic evaluation-Coronal CT scan has replaced plain films as the study of choice for evaluating LeFort fractures. The CT scan is superior in delineating these injuries since patients rarely have an isolated LeFort fracture and are more likely to have multiple fractures. If CT scan is not available, plain films should be used.
  • Treatment
  • The primary survey (ABCs) should be the focus of the initial evaluation of facial injuries.
  • Early intubation is critical in order to secure the airway since overwhelming edema can distort the anatomy necessitating cricothyroidotomy.
  • IV antibiotics are standard
  • Definitive care involves ENT, OMF, and plastic surgeons for repair of these complex injuries.

Nasal/Nasoethmoid Fractures

  • Nasal bone fractures are typically diagnosed based on history and physical alone.
  • Plain films with special nasal views can be obtained although they are rarely useful.
  • Plain films are often useful to delineate injury or fractures to adjacent sites.
  • Less severe injuries can be managed by closed reduction with nasal packing to provide internal support and a splint for external support.
  • Patients with a simple nasal fracture may be discharged home with follow-up in 5-10 days for further evaluation when the swelling has improved.
  • Nasoethmoid fractures should be suspected if the history and physical support a nasal bone fracture with additional evidence of ethmoidal bone involvement (e.g., CSF rhinorrhea or telecanthus).
  • Most CSF leaks resolve in 24-48 h and are self-limiting.
  • CSF leaks occur as a result of a cribriform plate fracture with dural penetration.
  • Patients with this type of injury typically require admission for observation secondary to the risk of a brain abscess or meningitis.
  • The use of antibiotics is controversial.
  • Thin section axial and coronal CT scan is the radiographic study of choice to evaluate asoethmoid fractures. Plain films are rarely useful.
  • Septal hematoma: This manifests as asymmetry or widening of the nasal septum.
  • There may be local discoloration although this unreliable as a means of diagnosis. If not adequately drained, the hematoma can become infected and cause subsequent necrosis and deformity of the septum.
  • Hematomas are drained either via needle aspiration or incision. It is important to make sure that all blood has been expressed from the hematoma.
  • After drainage, both nares are packed so that blood does not reaccumulate.
  • These patients need antibiotics and close follow-up.

TMJ Dislocations

  • A temporomandibilar joint dislocation can happen for many different reasons including jaw trauma or excessive opening of the mouth.
  • In this type of dislocation, the jaw typically deviates away from the side of the lesion since the condyle of the mandible is trapped anterior to the articular eminence. This is often due to a muscular spasm.
  • Unless there is a high index of suspicion for possible mandibular fracture, X-rays are not usually indicated.
  • Manual mandibular reduction can be performed in the emergency department.
  • Benzodiazepines or local anesthetic may facilitate the success of the reduction.
  • The patient should be placed in a Barton bandage and instructed to consume a liquid diet for several days and follow-up with an oral surgeon.
       
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