CBL OS: TRAUMA

Group A2
(04/05/2018)
 VIGNETTE 1
• Referral from Emergency Department during
on-call

• 20 year-old Malay male involved in MVA

• Difficulty in breathing when put in supine

position

• MO concerned about maxfac injuries causing

breathing difficulty
 AIRWAY COMPROMISED

• Maxillofacial injuries are usually complicated by a compromised airway.

On account of its location in the “crumple zone” of the face, even minor
injuries can result in significant casualty to the airway. The situation may be
aggravated by diminished consciousness, alcohol, and/or drug
intoxication, as well as altered laryngeal and pharyngeal reflexes, making
the patient vulnerable to the risk of aspiration.

• This scenario is complicated by the presence of broken teeth, dentures,

foreign bodies, avulsed tissues, multiple mandibular fractures, and massive
edema of glottis which can cause a direct threat to the airway.
 AIRWAY COMPROMISED

• Alcohol, drugs, and head injury along with ingested and pooled blood can
trigger nausea and vomiting. The act of vomiting prompts a rise in
intracranial tension which in turn increases the bleeding and salivation that
occludes the airway. Vomiting and risk of aspiration are particularly high
when patients are in supine position.

• In patients with multiple facial fractures, the displacement of maxilla or

mandible posteriorly can decrease the airway patency. Although of less
frequency, injuries to larynx and trachea can also create airway
embarrassment.
 STABILIZATION OF THE PATIENT
• Ensure that the patient won’t die immediately
• Ensure that patient does not have any injury/condition that will result in rapid
deterioration – by review the patient's vital signs, and perform a quick repeat
of the primary survey to assess patient response to the resuscitation effort.
• Oxygen therapy - nasal prong/ face mask/ endotracheal tube
• IV access – fluid therapy, blood replacement, give IV medications
• Monitor physiological parameters – ventilation rate, pulse, BP, urinary output,
arterial blood gas
• ECG monitoring
• Placement of catheters (eg: insert a urinary catheter to facilitate measuring
the response to fluid resuscitation)
 ADVANCED TRAUMA LIFE
SUPPORT

• The ATLS system divides the initial assessment into a primary and secondary
survey.

• The primary survey aims to identify immediate life-threatening injuries.

• The secondary survey aims to identify all other injuries that will require
treatment but are not immediately life-threatening.
 PRIMARY SURVEY
Aims of the initial evaluation of trauma patients:

• Stabilise the patient.

• Identify life-threatening conditions in order of risk and initiate supportive

treatment.

• Organise definitive treatments or organise transfer for definitive treatments.

 COMPONENT OF PRIMARY SURVEY
(ABCDE)
• A: Airway maintenance cervical spine protection

• B: Breathing and ventilation

• C: Circulation with haemorrhage control

• D: Disability: neurological status

• E: Exposure
 A: AIRWAY MAINTENANCE &
CERVICAL SPINE PROTECTION
• Assess airway and determine its adequacy. Remove any airway obstruction
(eg : denture, foreign body)

To open airway :
• Head tilt- chin lift or jaw thrust. If suspect cervical spine fracture, only do jaw
thrust to avoid cervical spine injury. Spine immobilisation (eg : cervical collar)
• Nasopharyngeal and oropharyngeal airway ,when simple manoeuvre is
inadequate to maintain airway (eg : tongue falls back)
• Nasal/ Orotracheal/ endotracheal intubation (when airway and breathing
compromised)
• Tracheostomy / cricothyroidotomy
 B: BREATHING & VENTILATION
• Assess and ensure adequate oxygenation and ventilation

To check for: Recognize and treat early !

• Jugular vein distension 1) Tension pneumothorax -
• Position of trachea requires needle thoracostomy
followed by drainage.
• Respiratory rate (>20/min)
• Oxygen saturation 2) Flail chest w pulmonary
contusion - ventilation

3) Haemothorax
4) Pneumothorax
 C: CIRCULATION & HAEMORRHAGE
Pallor
CONTROL
Cool peripheries
Overt & occult haemorrhage
Altered LOC
Shortness of breath
•LOOK
Decreased UO

Heart sounds
Carotid bruits •LISTEN
Precordial cardiac pulsation
Pulses – rate & quality, regularity,
symmetry
Capillary blanch test
(normal: Press, from white → red
•FEEL
blood loss: Press, remain white)
 C: CIRCULATION & HAEMORRHAGE
CONTROL
Primary cardiac causes
• Ishaemia
• Conduction defects Haemorrhage Control of haemorrhage
• Valvular disorders • Sublingual haematoma • Nasal pack
• Cardiomyopathy • Epistaxis (bleeding nose) • Intra oral pressure pack
• Otorrhea (bleeding ear) • Vessel ligation
Secondary causes • Severed vessel • Fracture stabilisation
• Drugs • Mobile #
• Hypoxia
BP CHANGES
• Electrolyte disorders
• 15-30% blood loss: diastolic
• Sepsis P drop
• 30-40% blood loss: BP drop
• >40%: shock
 D: DISABILITY (NEUROLOGICAL STATUS)

AVPU GCS ≤ 8 = unconscious.

• Alert ↓
Brain stem affected.
• Verbal response (Respiratory centre is in brain
stem)
• Pain stimuli ↓
Centre might shut down, patient
• Unconsciousness stops breathing.
↓
Intubation to protect airway and
facilitate ICP control.

*Normal practice to intubate at

GCS = 9
 E: EXPOSURE OR ENVIRONMENTAL
CONTROL
• Undress the patient, but prevent hypothermia.

• Clothes may need to be cut off but, after examination, attend to prevention
of heat loss with warming devices, warmed blankets, etc.

• Also check blood glucose levels.

• History taking (allergies, medication, PMH, last meal)

 GENERAL THERAPY
General medical therapy
• Administer oxygen and isotonic crystalloid fluids. Administer packed red blood cells
if indicated. Check the tetanus status of the patient and administer if indicated.
Antibiotics
• Administer antibiotics for open fractures until the fractures are repaired and the
soft tissue wounds are closed.
Pain management
• Use oral medications for minor injuries and parenteral medications if the patient
cannot take oral medications. For anti-inflammatory control, use ibuprofen,
naproxen, or ketorolac. For central control, use narcotics (eg, codeine,
oxycodone, hydrocodone, meperidine, morphine).
 EXAMINATION THAT CAN BE DONE FOR
MAXILLOFACIAL TRAUMA ASSESSMENT
• Look for facial asymmetry. Stand at the head of the bed and look down from above
to check the level of the cheekbones.
• Inspect for bruising, swelling, lacerations, missing tissue, foreign bodies and bleeding.
• Palpate for bony injury and crepitus systematically.
• Inspect the eyes. Examine eye movements. Assess pupils. Check for foreign bodies
and lacerations by everting the eyelids.
• Inspect the nose, looking for dislocation and telecanthus (widening and flattening of
the nasal bridge). Palpate for tenderness and crepitus. Look for septal haematoma,
lacerations and CSF rhinorrhoea.
• Ears: look for lacerations and CSF in the canal. Assess the tympanic membrane.
• Inspect the tongue and mouth.
 EXAMINATION THAT CAN BE DONE FOR
MAXILLOFACIAL TRAUMA ASSESSMENT
• Palpate the mandible and temporomandibular joint, looking for mobility or crepitus.
• Assessment for Le Fort fractures: put one hand on the anterior maxillary teeth, the
other on the nasal bridge. Only the teeth will move in a Le Fort I fracture. If the nasal
bridge moves, a Le Fort II or III fracture is present.
• Assess the teeth. Look for avulsed or mobile teeth. Look for jaw malocclusion. If a
tooth has been avulsed, note whether it has been aspirated.
• Tongue blade test: ask the patient to bite down hard on a tongue blade. They will
be in too much pain to do this if the jaw is fractured.
• Place a finger in the patient's ear canal to palpate the mandibular condyle. Ask the
patient to open and close the mouth. If there is pain or lack of movement, this
indicates a condylar fracture.
• Perform a complete cranial nerve examination.
 IMMEDIATE TREATMENT FOR
MANDIBULAR FRACTURE
• Temporary stabilization in the emergency department can be addressed
with the application of a Barton bandage. Bring the teeth into occlusion
and wrap the bandage around the crown of the head and jaw. This
stabilizes the jaw and greatly reduces pain and hemorrhage.

• A symphysis or body fracture can be reduced temporarily with a bridal wire

(a 24-gauge wire wrapped around 2 teeth on either side of the fracture).
This greatly reduces hemorrhage, pain and infection.
 INVESTIGATIONS FOR
MANDIBULAR FRACTURE
Plain X-rays:
• Panoramic view-as initial screening; shows the entire mandible, teeth and their roots;
• Lateral oblique views-when obtaining a panoramic radiograph is not possible eg
severely traumatized patients which unable to stand upright.
• Reverse Towne view-for excluding condylar and subcondylar fractures;
• Transcranial view-detecting condylar fractures and anterior displacement of the
condylar head;
• Occlusal view-accurate assessment of symphyseal fractures;

CT scan
• Suspected  intracapsular and high neck condylar fractures
VIGNETTE 2
 DPT INTERPRETATION

- Radiolucent fracture lines at parasymphysis

(left and right)
- Radiopacity on crown of 34&33, and 44&43. -
stabilizing wires
- Impacted canine with multiple missing teeth
on maxilla
 OTHER PLAIN RADIOGRAPHS

• Posteroanterior (mandibular view)

• Vertex occlusal view
• Lateral Oblique view
-fracture of body proximal to canine region
-fracture of angle,ramus and condylar region
 OTHER IMAGING MODALITIES

• CBCT
• Accurate
• 3D view - Better idea of fracture, better treatment
plan
 VIGNETTE 3

• Definitive
management
MANDIBULAR INNERVATION AND
BLOOD SUPPLY
 TYPES OF MANDIBULAR FRACTURE
Simple
• closed linear fracture of the condyle, coronoid, ramus & body of the mandible

Compound
• fractures of tooth bearing portion of the mandible

Comminuted
• compound fractures characterized by fragmentation of bone

Pathological
• results from an already weakened mandible by pathological conditions
SITES OF MANDIBULAR FRACTURE
 PATTERN, AETIOLOGY &
EPIDEMIOLOGY OF MANDIBULAR
FRACTURE
Pattern Aetiology Epidemiology
• Unilateral • MVA • Mandible (61%)
• Bilateral • Personal violence • Maxilla (46%)
• Multiple • Contact sports • Zygoma (27%)
• Comminuted • Industrial trauma • Nasal bone (19%)
• Falls
• Excessive muscle
contractions
 GENERAL SIGNS & SYMPTOMS OF
MANDIBULAR FRACTURES
• Swelling
• Pain
• Drooling of saliva
• Tenderness
• Bony discontinuity
• Lacerations
• Limited mouth opening
• Ecchymosis
• Fractured, subluxed or luxated teeth
• Bleeding from mouth
 CLINICAL FEATURES OF
MANDIBULAR FRACTURE
• Lip bruises
• Lacerations
• Swelling
• Loss of tongue control
• Sublingual heamatoma
• Step deformities or bony discontinuity
• Presence of paraesthesia or anaesthesia of the lip or chin (injured inferior
alveolar or mental nerve)
• Presence of trismus (spasm of the muscles of mastication)
 MANAGEMENT OF MANDIBULAR
FRACTURE
Conservative treatment (when only fractured line, no displacement)
• Control of pain , infection
• Temporary stabilisation of fractured part
• Soft diet
• Oral hygiene instructions
• Advice to patient not move the jaw vigorously
• Follow up
 MANAGEMENT OF MANDIBULAR
FRACTURE
Active treatment (if displacement occurs)
• Closed reduction
• Open reduction
• Fixation - Indirect fixation by IMF , direct fixation by bone plate , screws.
• Immobilization – The reduced / fixed fragments of bone are immobilized for
certain period – for healing . Can through IMF / bone plates and screws.
 FRACTURE REDUCTION
Closed Reduction TECHNIQUES
• Arch bars
• Ivy loops / eyelets
• Essig wire
• Intermaxillary fixation screws
• Splints
Essig Wire
• Bridal wires
Bridal wires

Open Reduction
• Direct osteogenesis (bone plates, transosseous wiring, circumferential wiring)
• Indirect skeletal fixation (pin fixation, bone clamps)
• Intermaxillary fixation using gunning type splints
● For cases where the preinjury occlusion is difficult to determine, particularly in partially
dentate and edentulous patients, the use of study models is very helpful. Model surgery
on the study models can be performed and acrylic splints fabricated to the new arch
form.These splints may include a lingual, palatal, or labial splint that will be secured in
place during surgery. The splints may be secured with the use of circummandibular
wires for the mandible or with circumzygomatic or piriform wires for the maxilla. A
maxillary splint also may be secured with palatal screws.
● For fully edentulous patients, dentures can be secured to the maxilla and mandible and
used for splints. If dentures are not available, impressions are taken of the jaws, and
acrylic base plates are processed and used as dentures. These are known as Gunning
splints. An arch bar also can be processed into the dentures, or holes can be placed
into the flange of the denture for intermaxillary wires. Prosthetic incisor teeth can be
removed for existing dentures, and space can be made in the acrylic to allow food
intake.
THANK YOU