definitive care

Upload: muditanatomy

Post on 15-Jul-2015

43 views

Category:

Documents


0 download

TRANSCRIPT

By Dr. Kayon Ratan. IInd Yr PG, Dept of OMFS. 15/10/2011

Content.1. 2. 3. 4. 5. 6. 7.

Introduction. Management of Maxillofacial trauma pt. Definitive treatment. Definitive treatment of each #. Complications. Conclusion. References.

Introduction.y In surgical terms, trauma may be defined as a

physical force, that results in injury. y The face is intimately related to self-image. It is the region responsible for our senses of smell and vision and for providing our voices and its resonance through the presence of the air sinuses. y It provides ant. protection for the cranium. y Definitive treatment is reqd so that all necessary procedures both preoperative and operative are performed in an orderly sequence.

The management of maxillofacial trauma pt.y Can be divided into:

First-aid & resuscitation. 2. Initial assessment. 3. Definitive treatment. 4. Rehabilitation.1.

Definitive treatment.Pre-op planning: I. Type of fixation reqd. II. The need for open reduction and application of direct trans-osseous wiring or bone plate. III. The type of IMF reqd. IV. The need for tracheostomy. Timing of operative procedure: y As early as possible usually b/w 5th 8th day.

At the time of admission: If pt is Unstable:

If Stable:

Pt should be shifted to OT for emergency treatment. Impression of jaws taken. Stabilization of mobile # fragment done..If medically stable

Reduction of simpler type of mid-face #.. Internal skeletal fixation applied.. Rest, nursing care and appropriate medicine.. Prior to definitive reduction of the facial #s.

Definitive treatmentOperative procedure: y A logical sequence of events should be followed according to now well-established principles. I. Tracheostomy: perform at outset if reqd. II. Facial lacerations: should have been cleaned and repaired at the time of admission. III. The reduction of associated mandibular #s: provide a useful guide..

DefinitiveIV. The occlusion:

teeth requiring extn should be extracted. y Alveolar #s should be reduced and stabilized. y In edentulous pt Gunning splint. V. Zygomatic #s: should be disimpacted now. VI. Disimpaction & reduction of the maxilla: using Rowe s maxillary disimpaction forceps and, or Hayton-Williams maxillary forceps.y

DefinitiveVII. Open reduction:

Any # which require exposure and direct transosseous wiring, bone plates should now be treated. y At this stage, concomitant Naso-ethmoid #, together with #s of the Orbit and Zygomatic bones should be reduced definitely and fixed. VIII.Skeletal fixation. IX. Temporary IMF.y

DefinitiveX. Nasal #(not involving NOE complex): y Manipulation of the nasal pyramid done now. y Naso-endotracheal tube may be changed to an oral-

endotracheal tube to facilitate the manipulation. XI. Definitive IMF: y At this stage it will be necessary to decide if the IMF is to be reapplied. y If tracheostomy is not done then it may be prudent to consider leaving the jaws open until the airway is regarded as safe.

DefinitiveImmediate postop care: y Timing of extubation. y Tracheo-bronchial toilet. Decided by the anesthetist. y Control of airway. Postoperative treatment: I. General management of the pt. II. Maxillofacial management: y External skeletal appliances should be checked for stability and adjusted accordingly.

Definitivey IMF should be inspected for rigidity, and wire y y

y y

impingement. Proper oral hygiene maintenance. Sutured lacerations and surgical incisions should be kept scrupulously clean and instruction given on the timing of suture removal. Nasal plaster may require replacement after 3-4 days as the soft tissue swelling resolves. Initial chemosis of the conjunctiva may require protection by the application of 1% chloramphenicol ophthalmic ointment.

Pan-facial #.

Rehabilitation: The aim is to correct and mask deformity so that the pt is able to return to work and the home environment. I. General rehabilitation. II. Maxillofacial rehabilitation: y Facial scar may require secondary correction. y Some severe residual deformities may be permanent requiring psychiatric support. y Prosthetic replacement. y Restorative treatment.

Definitive treatment of each #

Classification of # in Maxillofacial trauma pt.Dentoalveolar #. II. Mandibular #. III. Lefort I #. IV. Lefort II #. V. lefortIII #. VI. Nasal #. VII. NOE #. VIII.ZMC #. IX. Orbital #.I.

Mandibular #:Indications for closed reduction: i. Non-displaced favourable #s. ii. Grossly comminuted #s. iii. #s exposed by significant loss of overlying tissue. iv. Edentulous mandibular #s. v. In children with developing dentition. vi. Coronoid process #s. Indications for ORIF: i. Displaced unfavourable #s. ii. Multiple #s of the facial bones. iii. #s of an edentulous mandible with severe displacement of the # fragments. iv. Edentulous maxilla opposing a mandibular #. v. Mid-face # with B/L displaced condylar #s. vi. Special systemic conditions contraindicating IMF. vii. Malunion.

Mandibular #...A. Closed reduction and indirect skeletal fixation.

Direct interdental wiring. II. Indirect interdental wiring (eyelet or Ivy loop). III. Continuous or multiple loop wiring. IV. Arch bars. V. Cap splints. VI. Gunning-type splints. VII. Pin fixation.I.

B. Open reduction and direct skeletal fixation.

Transosseous wiring. II. Plating. III. Intermedullary pinning. IV. Titanium mesh. V. Circumferential straps. VI. Bone clamps. VII. Bone staples. VIII.Bone screws.I.

z

CONDYLE #:Indication of Functional/conservative therapy: I. In growing children. II. If the pt is able to establish and maintain a normal occlusion with a minimal amount of discomfort. III. Intra-capsular # if the pt has minimal symptoms. IV. Systemic risks of submitting the patient to general surgery and IMF.

Indications for Closed treatment of Condylar #: I. In children: A. Where there is a risk of ankylosis/defective development: Close proximity of the #ed condylar neck to the glenoid fossa.Intracapsular # # dislocations with gross telescoping.

Compound #. B. Where there is a major disturbance of occlussion: In b/l # dislocations with open bite and possible retro-

positioning of the mandible. II. In adult: A. Unilateral # exhibiting deviation or displacement. B. B/L # where the occlusion is normal.

y The absolute indications for open treatment of condylar fractures are: I. II. III. IV.

V. VI.

Bilateral fractures with gross displacement. Considerable dislocations. When closed treatment does not re-establish occlusion. Concomitant fractures of other areas of the face that compromise occlusion and for which rigid internal fixation will be used. Foreign bodies such as firearm projectiles and Dislocation of the condyle to the middle cranial fossa.1,30

Lefort #sIndications for ORIF: I. Minimally displaced #. II. Delayed reduction or severe impaction resisting closed reduction. III. In the absence of comminution. IV. When # fragment is dentulous and un# fragment is edentulous. Indications for Ext. skeletal fixation: I. Severely comminuted # Those who can t undergo bone grafting. Those who can t endure IMF.

Indications for Int. skeletal suspension: I. For maxillary #s associated with the intact mandible, or the #ed mandible which can be rendered stable by open reduction. II. In the presence of severe scalp lacerations and depressed #s of the skull. III. Head injury with cerebral irritation. IV. Mentally deranged pt.

Internal skeletal suspension.

Indication for Transfixation with Kirschner wire: I. Lefort-II # without comminution. II. Severely comminuted # of the mid-face. III. In elderly or ill pt. IV. Maxillofacial # in the presence of skull # where the use of halo-frame or POP headcap happens to be contraindicated.

Lefort-I #.y Reduction & immobilization for minimally displaced

#,

ORIF (ideally).

Closed reduction (alternatively) followed by IMF for 1 month, and in case of severe comminution 6wks. y If fragment mobile Digital pressure used to reduce # IMF/RF y If not mobile digitally Manipulation with Rowe s or Hayton-William s forceps.

Lefort-I

Lefort-II #.Closed reduction with a Rowe disimpaction forceps. IMF to provide the anterior-posterior position of the # for a minimum of 4wks. Internal skeletal suspension.

Lefort-IIAlternatively ORIF Atleast 3 or preferably 4 pt fixation is necessary. Sites to be exposed & fixed depends on The need to explore orbital floor or reconstruct the orbital rim, or both, and to reconstruct the N-F region.If not involved Minor involvement Major involvement

BL I/O exposure Simpler floor or rim of the Z-M Injury is best approsuture. ach by T.C approach.

For major reconstructive effort one of the skin incision is used.

Lefort-II

Lefort-III #.A stable outer framework is established first. Meticulous reduction & immobilization of the F-Z, Z-T, and N-F sutures. Appropriate reduction of the maxilla to the midface inferiorly. Proper occlusion must be established.

Lefort-IIIAfter establishing a Stable outer framework. Reconstruct the nasal skeleton and the floors of the orbit. Correct any Lacrimal system disorders. Re-establish the proper positioning of the medial canthal ligaments.

Lefort-III

Coronal CT scan

Palatal #. Treatment depends upon: a) Identification of the type of #. b) State of dentition. c) Associated maxillary or mandibular #.

Type Ia #

Application of a segmental arch bar or orthodontic brackets. May be supported by ORIF.

PalatalApplication of arch bar + ORIF. 2-4 wks of IMF recommended. Type II, III, IV & VI # - Sequential approach. Establishment of pre-injury occlusion. Application of maxillary arch bar to apply a tension band. Temp. IMF to confirm preliminary # alignment. ORIF of palatal vault. IMF again ORIF of piriform & alveolar ridge segment. For 2-4 wks. Guiding elastics & soft diet upon release. Type Ib#

PalatalType V # Application of an acrylic palatal splint May be applied by circumdental wires with or without arch bars. ORIF contraindicated.

Nasal #.Timing of treatment: y Less controversial. y Isolated # can be reduced in the 1st 24hrs provided that the swelling is not excessive. y When associated with other mid-face #, nasal component should be reduced at the same operation. y However, other mid-facial # should be reduced & stabilized prior to reduction of the nasal #.

NasalLateral Nasal injuries Closed manipulation by outfracture with Walsham s forceps. Final centralization of the nasal septum by Asch s forceps. y If septal # present then Sub-mucous resection of the nasal septum, as advocated by Harrison (1979), should be considered.

NasalAnterior nasal injuries Manipulation with Walsham s forceps followed by centralization with Asch c forceps. Sub-mucous resection of the nasal septum. Rigid internal nasal support should be done as described by Sear(1977) using S.S intranasal splint. For treating plane 2 injuries, primary submucous resection should be used with caution (Stranc, 1979). Resection should be reserved for pts in whom there is no evidence of significant loss of profile or support but who exhibit airway obstruction due to distortion of the septum.

NOE #.Treatment should consist of : a) Specific diagnosis and typing. b) Early surgical intervention. c) Careful anatomic osseous reduction. d) Internal rigid fixation when needed. y If a medial wall blow out # or an obstruction of the

lacrimal system, or both, are diagnosed Should be corrected before addressing the M.C deformity, after proper repositioning of the nasal bones & bony reconstruction of the region.

NOE

NOE...various surgical approaches.

NOEType I #: Managed best by 3 point stabilization.i. i. i.

R.F of the N-F junction to the Nasal complex. Fixation of the N.C to the Maxillary buttress. Stabilization of the N.C to the I.O rim at the # associated with the frontal process of the maxilla.

NOEType II #: Small bony fragments are anatomically reduced with 28-30 gauge intra-osseous wiring. Rigid Int. fixation of the Frontal process of the maxilla to the N.C, and the N.C to the frontal bone is reqd.Either Or

Reattachment of the M.C.L completed with T.N wiring

Rigid plate applied below the ant. lacrimal crest.

Plating of the fragments when applicable.

Type III #: Careful reconstruction of the osseous segment is completed. Anatomic reduction is gained via R.F plates superiorly at the orbital area & inferiorly at the maxilla. Canthoplasty (uni or bi) may have to be performed. Direct trans-nasal wiring of the M.C.L to a stabilization area that is post. and slightly sup. to the normal position is accomplished..

Comminuted NOE #

Zygoma Fracturesy The zygoma has 2 major components: i. Zygomatic arch. ii. Zygomatic body. y Blunt trauma most common cause. y Two types of fractures can occur: i. Arch fracture (most common). ii. Tripod fracture (most serious).

Zygomatic Arch #s Imaging Studies & Treatment.y Radiographic

imaging:y Submental view (jug

handle view)

y Treatment:y Ice and analgesia. y MO exercises. y Open elevation &

fixation if needed.

Zygoma Tripod Fracturesy Tripod fractures

consist of fractures through:y Zygomatic arch y Zygomaticofrontal

suture y Inferior orbital rim and floor

Zygoma Tripod #s Treatment.I.i.

Low-energy #:Ice and analgesics. ii. Delayed operative consideration 5-7 days . iii. Broad spectrum antibiotics . iv. Tetanus.

II. Middle-energy #: y Gillies approach can be used to elevate the ZMC. y If the reduction is unstable, or if there is question

regarding the accuracy of the reduction, ORIF should be done. y High-energy #: ORIF is advocated.

Sequence of Int. Fixation in ZMC #:For middle-energy # with exposure of all three anterior buttresses, The FZ # may be stabilized temporarily with an inter-osseous wire.

This is followed by fixation of the Z-M # and the infra-orbital rim.

The temporary wire at the F-Z # is replaced with a plate.

The orbital floor is reconstructed after the zygoma has been restored to its correct 3D position. In high-energy #, the zygomatic arch should be reconstructed first.

Operative techniques of the # of the Orbital floor.Objectives: Repositioning of displaced orbital tissues. Reduction of fractures. Stabilization of fractures. Restoration of the orbito -antral partition. Elimination of interference with ocular movements. Preservation of the orbital volume and periorbital fat. Approach to the antrum. Antral pack.

a. Gillies b. Lateralbrow c. Lateral canthal d. Transcutaneous e. Medial canthal

Subtarsal & Subciliary

CSF Leakage.y CSF leakage should be noted immediately after trauma y Blood clot or brain tissue may obstruct fluid passage y After lysis of clot or Increased intracranial pressure leakage is seen y Mobile midface fractures often creates pumping actioncause increased CSF leak

CSF

y Higher the level of fractures more chances for CSF Rhinorrhoea, Otorrhoea. y Frequently misseda) Reclining position. b) Blood stained.

y Later clean watery discharge.

How to detect?y Pt position - Sitting and leans forward (drips from nose) y Salty / Metallic taste y Tram line y Double halo - when dropped on gauze sponge y Classical bull s eye ring will develop

CSFy Glucose test (>30mg/dl) y Location of leak-CT scan y Intrathecal injection and assaying in different locations y Fluorescein & radioactive tracers (Indium)

Precautiony Pre-nasal route intubation avoided (but in maxillofacial injuryit is safest & effective)

y Pt in

semi recumbent position y Should noty Strain y Sneeze y Blow the nose

y Avoid packing nose or ear- prevent retrograde infection y Infection- Meningitis y Antibiotics

Treatmenty Fracture reduction. y Dural repair. y Lumbo peritoneal shunting. y Antibiotics

.

Hemorrhage management.y NOE # with mid-face bleeding manifest itself as Epistaxis. y To locate the site of bleeding good visualization is needed y Mucous membrane should be shrunken & anesthetized with Phenylephrine hydrochloride (Neo-synephrine) or 4% cocaine solution or both y Cotton pledget soaked with vasoconstrictor y Cauterization with silver nitrate solution

y Merocel sponge y Anterior nasal pack y Posterior nasal pack y Pressure balloon If bleeding not stopped y Arteriogram y Embolization or Ligation

Retrobulbar haemorrhageSigns: Globe very hard on palpation Increased intraocular pressure on tonometry Dilating pupil Loss of direct reflex Preservation of consensual light reflex Slight pallor of the optic disc Cherry-red macular spot (rare) Opthalmoplegiamovement)

Proptosis Marked Subconjunctival odema and ecchymosis

Symptoms: Pain (aggravated by attempted

Decreasing visual acuity or blindness Diplopia

Retrobulbar TreatmentMedical treatment: y 20% mannitol (2g/kg of B.W i.v for 24hrs with no more than 12.5g in 3-4mins). y Acetazolamide sodium 500mg i.v stat. y Methylprednisolone 1g i.v stat. y Papaverine 40mg i.v If no significant improvements within 15-20 mins then Surgical intervention is recommended. y It should be continued after surgical intervention at least for the next 24 hrs. II. Surgical intervention: y Before any surgical exposure is performed, a rapid decompression must be effected by division of the orbital septum..I.

If prior incision to orbital floor is present it is used to provide a rapid access to the orbit..(if unsuccessful) The intra-conal space may be decompressed.. (if unsuccessful) The antrum should be opened. Suction carried out with caution. Supplement all these with retrograde injection of spasmolytic agents through a canula tied into the S.O artery.III. Paracentesis of the ant. chamber : y A small knife is introduced into the ant. chamber through

the limbus along a line parallel to the iris and ant. to tha canal of Schlemm (should be carried out by an ophthalmologist).

Diplopia.y Common complication in mid-facial trauma. y May be temporary or permanent, if not treated. y It is caused by interference with the function of the

EOM. y The possibility is greatest when the traumatic assault results in an inf. displacement of the zygoma with # occurring at the level of F-Z suture. y Forced duction test diff. b/w neurologic damage to the affected muscle and entrapment of the muscles & edema.

DiplopiaTreatment: y Displaced zygoma should be restored as soon as practicable. y Repair of orbit should be done as soon as possible ideally. y Pt should receive steroids for 5-7 days to determine if the diplopia is secondary to edema or hemorrrhage, (or both) of the orbital muscle or fat.

DiplopiaTrap-door injury: Tissue gingerly dissected from the crack. (If floor defect is large) Contents are raised into orbit. Elevation through rim incision. Elevating the content through maxillary sinus. Seal the defect.

Enophthalmos.y Causes:in size of the orbit in orbital content Disruption of the ligamentous structure of the globe

Axis of the globe extends from lat. orbital rim to the ant.

portion of the lacrimal bone. y Blow-out #, either isolated or along with zygoma or rim #, must extend far enough behind the axis of the globe to. y More than 3mm of deficit is considered aesthetically unacceptable.

Enophthalmos TreatmentAll herniated orbital tissue must be elevated.(complete exploration of the orbit, with freeing of all soft tissues from herniated positions, is essential).

Secured with autologous bone graft/ alloplastic graft. A wedge shaped graft placed on the floor with the thicker portion in the post. portion of the graft, will give an anterior and somewhat superior projection to the globe.

Conclusion.y The treatment of Maxillofacial fractures is a challenge

since it is very rare that a fracture occurs as a single block. Mostly it is comminuted with fracture of multiple bones. y Last but not the least, we should try our level best to restore both the esthetic as well as functional aspect of the facial region as face is the first impression of a person .

Thank you

References.y Maxillofacial injuries - Rowe & William. y Oral & Maxillofacial trauma, Vol. 1 & 2 y Peterson s principles of OMFS. y Maxillofacial surgery

Fonseca.

Peter Ward Booth y Mandible & Middle third # - Killey & Kay.