http://decode-medicine.blogspot.com/ by sun yaicheng

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

19. Teardrop
Herniation

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

31. TM Joint Dislocation

32. TM Joint Dislocation

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