Midface fractures

Editor's Notes

• #2: Fractrure of maxilla and its associated bones commonly referred to as fracture of middle third.
• #8: Each individual facial bone has comparatively less strenghth. It gains strength by articulating with each other. In case of extensive facial trauma also blood supply remains intact, Because of most of the facial bones are clothed in mucosa, And periosteal blood supply remains intact.
• #10: The vertical pillars are formed firstly medially by the piriform rims which continue superiorly as the frontal process of the maxilla. Secondly the zygomatic buttresses which continue superiorly with the lateral orbital rims form the lateral pillars. The most caudal pillars are the pterygoid plates The horizontal pillars are formed by the frontal bar (composed of the supraorbital rims and nasal process of the frontal bone), the zygomatic arch, infraorbital rims, and the nasal bridge and finally the alveolar process of the maxilla.
• #11: This buttresses transmits occlusal stress from the alveolar processes to the skull base.
• #14: 2nd largest bone of face Two maxilla forms most part of the middle 3rd It contributes in formation of 1.Face 2.Nose 3.Orbit 4. Mouth 5. Infratemporal fossa 6. Pterygopalatine fossa 1 body 4 processes
• #15: 2 in number Largest of the paranasal sinuses Communicate with other sinuses through the lateral wall of the nose The average dimensions of the sinus are approximately 3.5 anterioposteriorly 3.2cm height and 2.5cm width Volume -15 to 30ml Function decrese Wt of the skull increase the resonance of voice Humidifying and heating of inhaled air
• #16: Also known as malar bone It plays important role in maintaining shape of the face & cheek. it articulates with the temporal, maxillary, frontal and sphenoid bones. its lateral surface is convex forming the prominence of the cheek.
• #35: The horizontal fracture line is seen above the apices of the teeth, which detaches the tooth bearing portion of the maxilla from the rest of the facial skeleton.
• #40: Separation of the block from the base of the skull is completed vie the nasal septum and may involve the floor of the anterior cranial fossa.
• #44: It also known as cranio facial dysjunction. Supra zygomatic Transverse or High level fracture.
• #45: The force is usually applied from the lateral direction with a severe impact. Many of time lefort 3 fracture seen in combination with lefoer 1 & 2 or cranial base fracture.
• #50: SWELLING After a facial injury, inflammatory exudates accumulates to protect the injured tissue. Thus facial asymmetry occurs.. and The area becomes inflamed with pain, tenderness and redness. BRUISING its a discoloration or also called “contusion,” appears on the skin due to trauma. Its a type of hematoma. The injury causes tiny blood vessels called capillaries to burst. The blood gets trapped below the skin or mucosal surface.(treatment cold application compression) CIRCUMORBITAL ECCHYMOSIS bleeding that occurs due to fractured bones escapes in the subcutaneous plane it produces circumorbital ecchymosis. If it travels in the subperiosteal plane then subconjunctival haemorrhage occurs which is bright red in colour. PERIORBITAL OEDEMA due to accumulation of inflammatory exudates around eyes.
• #51: (CSF) RHINORRHOEA occurs when there is a fistula between the dura and the skull base and discharge of CSF from the nose. it occurs due to fracture of ethmoid, sphenoid, frontal, or fracture of anterior skull base. LENGHTHENING OF MIDFACE occurs due to complete separation of midface to the skull base. Also knoen as DONKEY FACE appearance. In DISH FACE deformity face appears concave due to separation of fronto-zygomatic suture and depreesed nasal bones. ENOPHTHALMUS posterior displacement of eyeballwithin the orbit due to changws in volume of the orbital contents due to fracture of orbital bones. PROPTOSIS is a outward displacement of eyeball within the orbit due to retrobulbar hematoma. DIPLOPIA it is also known as double vision. Occurs due to entrapment of intra-ocular muscles.
• #52: It is not found in blood, mucous, or tear Characteristics of normal spinal fluid are below: [1, 2] Total volume: 150 mL                                      Color: Colorless, clear, like water Opening pressure - 90-180 mm H 2O (with patient lying in lateral position)                  Osmolarity at 37°C: 281 mOsm/L Specific gravity: 1.006 to 1.008 Acid-base balance:                                                            pH: 7.28-7.32                                                 Pco2: 47.9 mm Hg                                           HCO3-: 22.9 mEq/L                                          Sodium: 135-150 mmol/L                                                 Potassium: 2.7-3.9 mmol/L                                                        Chloride: 116-127 mmol/L                                                          Calcium: 2.0-2.5 mEq/L (4.0 to 5.0 mg/dL)                                   Magnesium: 2.0-2.5 mEq/L (2.4 to 3.1 mg/dL)                               Lactic acid: 1.1-2.8 mmol/L                                                        Lactate dehydrogenase: Absolute activity depends on testing method; approximately 10% of serum value                                       Glucose: 45-80 mg/dL                                                     Glutamine - 8-18 mg/dL Lactate dehydrogenase (LDH) - <2.0-7.2 U/mL Proteins: 20-40 mg/dLAt different levels of spinal tap:      Lumbar: 20-40 mg/dL                 Cisternal: 15-25 mg/dL Ventricular: 15-10 mg/dL   Normal CSF proteins concentration in children: Up to 6 days of age: 70 mg/dL Up to 4 years of age: 24 mg/dL Electrophoretic separation of spinal fluid proteins (% of total protein concentrations)Prealbumin: 2-7% Albumin: 56-76% a1-Globulin: 2-7% a 2-Globulin: 3.5-12% b-and g-globulin: 8-18% g-Globulin: 7-12% Oligoclonal bands - absent ImmunoglobulinsIgG: 10-40 mg/L IgA: 0-0.2 mg/L IgM: 0-0.6 mg/L k/l ratio: 1 Erythrocyte count:Newborn: 0-675/mm3 Adult: 0-10/mm3 Leukocyte count: Children: Younger than 1 year: 0-30/mm3 Age 1-4 years: 0-20/mm3 Age 5 years to puberty: 0-10/mm3 Adult: 0-5/mm 3 Antibodies, viral DNA – None Bacteria (Gram stain, culture, VDRL) – Negative Cancerous cells – None Cryptococcal antigen – None
• #53: Subcutaneous Emphysema – occurs when gas or air trapped under the skin. In lefort fracture it occurs due to sinus wall fracture. Impairment of sensation – occurs due to nerve injury mostly seen in lefort 2 fracture due to injury to infraorbital nerve.
• #55: Guiren’s sign – it is a ecchymosis seen in posterior palate due to greater palatine vessels. Fractured cusps – mostly seen in impacted type of fracture, occurs when blow to chin in superior direction. Midline diastema – occurs due to midline split type of palatal fracture.
• #56: After local trauma, red blood cells are phagocytosed and degraded by macrophages. The blue-red color is produced by the enzymatic conversion of hemoglobin into bilirubin, which is more blue-green. The bilirubin is then converted into hemosiderin, a golden brown color, which accounts for the color changes of the bruise.[3] Hematomas can be subdivided by size. By definition, ecchymoses are 1 to 2 cm in size or larger, and are therefore larger than petechiae (1–2 mm or less) or pigmented purpuric dermatosis (0.3 to 1 mm).[3] Hematomas also have a more diffuse border than other purpura.[4] Generally speaking, dermatologists prefer to differentiate between purpurae, petechiae, and ecchymoses as descriptive technical terms. Other specialties such as internal medicine will frequently call all of these ecchymoses, because the finer distinction is not relevant in the particular case.
• #57: of epistaxis occur in the anterior part of the nose, with the bleeding usually arising from the rich arterial anastomoses of the nasal septum (Kiesselbach’s plexus). Posterior epistaxis generally arises from the posterior nasal cavity via branches of the sphenopalatine arteries.
• #58: due to the medial and inferior traction of the medial and lateral pterygoid on the mobile maxillary fragment.
• #65: Traumatic CSF leaks usually result from tears in the dura at the skull base that allow CSF to escapefrom the subarachnoid space into the nasopharynx, the paranasal sinuses, or subcutaneously. The floorof the anterior cranial fossa, particularly the cribriformplate area, is thin, and the dura at this site firmlyinvests the olfactory fissure where the olfactory nerve penetrates the skull.
• #66: Most cases of epistaxis occur in the anterior part of the nose, with the bleeding usually arising from the rich arterial anastomoses of the nasal septum (Kiesselbach’s plexus). Posterior epistaxis generally arises from the posterior nasal cavity via branches of the sphenopalatine arteries.8 Such bleeding usually occurs behind the posterior portion of the middle turbinate or at the posterior superior roof of the nasal cavity. The vast majority of nose bleeds occur in the anterior (front) part of the nose from the nasal septum. This area is richly endowed with blood vessels (Kiesselbach's plexus). This region is also known asLittle's area. Bleeding farther back in the nose is known as a posterior bleed and is usually due to bleeding from Woodruff's plexus,a venous plexus situated in the posterior part of inferior meatus.[6]Posterior bleeds are often prolonged and difficult to control. They can be associated with bleeding from both nostrils and with a greater flow of blood into the mouth.[7]
• #76: Submento vertex also known as “JUG HANDLE VIEW” Important in assessment of zygomatic arch and mandible body fracture Lateral view is important in assessment of lefort fractures, orbital fractures, condyle, angle, body and coronoid process fractures
• #77: This view is important to rule out facial fractures. MAXILLA MAXILARRY SINUS ZYGOMA ZYGOMATIC ARCH NASAL ORBITAL RIMS If this lines bilaterally symmetrical then it is considered as normal , but if they are not symmetrical, brich or discontinuity is there then fracture is suspected.
• #82: PTERYGOID PLATE FRACTURE IS SEEN IN ALL LEFORT FRACTURES.
• #88: Fracture of pterygoid plates are present in all type of LeFort fractures. H = Hemosinus
• #91: BLOW OUT FRACTURE … TEAR DROP SIGN SEEN DUE TO ENTRAPEMENT OF ORBITAL CONTENTS IN THE MAXI. SINUS
• #92: Blue arrows define LeFort II fracture. Red arrows define the LeFort III fracture
• #95: Preparation for a trauma patient occurs in two different phases PREHOSPITAl PHASE it includes coordination with experienced prehospital agencies & team work to transfer the trauma patient to trauma centre. & to provide primary care. Inform to the hospital is equally important HOSPITAL PHASE Advance planning for the trauma patient’s arrival is essential. A resuscitation area should be available for trauma patients. Properly functioning airway equipment (e.g., laryngoscopes and tubes) should be organized, tested, and strategically placed where it is immediately accessible.
• #98: The airway should be assessed first in any trauma. Initially, the chin-lift or jaw-thrust maneuver is recommended to achieve airway patency If the patient is able to communicate verbally, then the airway is not likely to be obstruct.
• #99: The patient’s neck and chest should be exposed to adequately assess position of the trachea, and chest wall excursion. Visual inspection and palpation can detect injuries to the chest Auscultation should be performed to ensure gas flow in the lungs
• #100: Definitive bleeding control is essential along with appropriate replacement of intravascular volume Initially circulation can be determined by following points Level of consciousness When circulating blood volume is reduced, cerebral perfusion may be critically impaired, resulting in altered levels of consciousness skin colour the patient with hypovolemia may have ashen, gray facial skin and pale extremities. Pulse A rapid, thready pulse is typically a sign of hypovolemia, but the condition may have other causes.
• #101: A minimum of two large-caliber intravenous (IV) catheters should be introduced. At the time of IV insertion, blood should be drawn for type and crossmatch and baseline hematologic studies A bolus of 1 to 2 L of an isotonic solution may be required to achieve an appropriate response in the adult patient. All IV solutions should be warmed either by storage in a warm environment (i.e., 37°C to 40°C, or 98.6°F to 104°F) or fluid-warming devices
• #103: GCS below 13 patients requires definite care Those patients should be immediately transferred to the ADVANCED TRAUMA CENTER.
• #104: After the patient’s clothing has been removed and the assessment is completed, the patient should be covered with warm blankets or an external warming device to prevent hypothermia Intravenous fluids should be warmed before being infused
• #105: While assessing and managing a patient’s airway, great care should be taken to prevent excessive movement of the cervical spine. The patient’s head and neck should not be hyperextended, hyperflexed, or rotated…(this should be done based on history) JAW THRUST maneuver shold be done in spinal injury.
• #107: Goals of treatment of maxillary fractures: Precise anatomical reduction to the cranial base above and to the mandible below,Stable fixation of the reduced fragments,Preservation of blood supply to the fractured site and Restoration function
• #110: Restoration of occlusion is must for correct reduction and Fixation is maintained by external/internal skeletal fixation until consolidation is achieved and Immobilization for 6-8 weeks to stable segments , IMF for 3-4 weeks.
• #124: Plating system depends on: Rigidity of plate Width and shape Diameter and number of screws Increase in width provides more stability towards rotational forces.
• #129: In that incision is made 5-10mm above the attached gingiva in the free mucosa around the maxillary arch. This clinical photograph shows the injection of a local anesthetic. The incision is made at least 5-10mm above the mucogingival junction using a scalpel blade or an electrocautery. The incision is carried down through the mucosa, submucosa, underlying facial muscles and periosteum  The incision is made onto the bare bony surface In edentulous patient crestal incision should be made. 
• #130: The smaller, straight unpadded blade is first introduced in the nasal floor and after it larger blade is entered into mouth and the forceps is closed to engage floor of nose and hard palate.Movements-includes upwards- to effect disimpaction of pterygoid plates down. Downwards- to mobilse the maxillae parallel to the inclined plane of cranial base. In case of split palate Hayton williams forceps can be used along with the Rowe’s forceps
• #131: 2 plates on nasomaxillary buttress. And 2 plates on zygomatico-maxillary buttress.
• #135: It is also known as, BI-TEMPORAL aproach. The coronal or bitemporal incision is a versatile surgical approach to the upper and middle regions of the facial skeleton, including the zygomatic arch. It provides excellent access to these areas with minimal complications. A major advantage of this approach is that most of the surgical scar is hidden within the hairline. When the incision is extended into the preauricular area, the surgical scar is unnoticeable.  The incision is kept approximately 4 cm behind the hairline. This incision is preferred in most of the female patients and male patients with no signs or family history of baldness. (Zigzag incisions may be used to make the scars less noticeable) The layer of dissection and the extent of exposure depend on the particular surgical procedure for which the coronal approach is used. In some instances, it may be prudent to perform a subperiosteal elevation of the coronal flap from the point of incision. The periosteum is freed with a scalpel along the superior temporal lines as one proceeds anteriorly with the dissection, leaving the temporalis muscles attached to the skull. In most cases, however, dissection and elevation of the coronal flap are in the easily cleavable subgaleal plane. The deeper pericranium may be used as a separate vascularized coronal flap for defect coverage.
• #136: fronto-nasal suture Infra orbital margin Zygomatico-maxillary butress
• #143: fronto-nasal suture Fronto-zygomatic suture Zygomatico-temporal suture