zygomatio-frontal Fracture

zygomatio-frontal Fracture - Management of Maxillofacial...

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Unformatted text preview: Management of Maxillofacial Trauma Zygomatic complex fractures 1 Contents Contents Fracture of the zygomatic complex and arch Fracture Orbital floor fractures Traumatic injury to the frontal sinus Naso-ethmoial orbital fracture (NEO) Nasal fractures 2 Zygomatic bone complex Anatomy Star-shape like with four processes Frontal process Temporal process Buttress Orbital floor (Maxilla and GWSB) Temporal fascia and muscle Masseter muscle 3 Zygomatic complex and arch Zygomatic fracture fracture The malar bone represent The a strong bone on fragile supports, and it is for this reason that, though the body of the bone is rarely broken, the four processes- frontal, orbital, maxillary and zygomatic are frequent sites of fracture. sites HD Gillies, TP Kilner and D Stone, HD 1927 1927 Zygomatic bone fractured as a block near its principle three suture lines and often displaces inwards to a greater or lesser extent. 4 Occurrence Occurrence •As isolated fracture •In combination with other middle third fracture •With internal orbital fracture (blow out) Observed in (>50%) of middle third fracture (in developed countries due to assaults) (in The zygomatic arch fracture can be The isolated in most of the cases isolated 5 Signs and symptoms Periorbital ecchymosis and edema Flattening of the malar prominence Flattening over the zygomatic arch Pain and tenderness on palpation Ecchymosis of the maxillary buccal sulcus Deformity at the zygomatic buttress of the Deformity maxilla maxilla Deformity at the orbital margin 6 Trismus Abnormal nerve sensibility Epistaxis Subconjunctival ecchymosis Crepitation from air Crepitation emphysema emphysema Displacement of palpebral Displacement fissure (pseudoptosis) (pseudoptosis) Unequal pupillary levels Unequal Diplopia enophthalmos 7 Clinical examination Inspection Palpation Visual examination Eye movement Diplopia Pupil reaction 8 Radiographical evaluation Nothing is more valuable to the surgeon in Nothing determining the extent of injury and the position of the fragments-both before and after operation- than a good skiagram (radiograph) (radiograph) HD Gillies, TP Kilner and D Stone, 1927 9 Occipitomental view (Posterioanterior oblique) (water’s view) 10 10 submentovertex Recommended for isolated zygomatic arch fracture 11 11 CT scan Coronal sections Axial sections 12 12 Treatment Treatment Timing: Timing: As early as possible unless there are ophthalmic, As cranial or medical complications cranial Preiorbital edema and ecchymosis obscure the Preiorbital fine details of the fracture, intervention can be postponed but not more than a week postponed Indications: •Diplopia •Restriction of mandibular movement •Restoration of normal contour •Restoration of normal skeletal protection for the eye 13 13 Classifications Classifications Displacement Displacement Rotation along the axis of FZ processes Anterio-posterior displacement Rotation along the prominence of the bone Medio-lateral displacement Extension of the fracture along processes points of fractures Combination with other injuries 14 14 Treatment Treatment The methods of treating a fractured malar bone recommended by the various writers who have reported cases include simple digital manipulation under genre real anesthesia, external manipulation by means of a cow-horn dental forceps grasping the edges of the bone, traction and elevation by means of wire or heavy bone elevators passed through small local external incisions, and elevation via incision in the mucosa of the ginigival sulcus at the canine fossa. Our technique, which has now been used successfully in a number of cases, differs from those mentioned. HD Gillies, TP Kilner and D Stone, 1927 HD 15 15 Methods of reduction Temporal approach (Gillies et al Temporal 1927) 1927) Suitable for isolated zygomatic fracture with good stability afterwards 16 16 Methods of reduction Percutaneous approach (malar hook, Percutaneous Carroll-Girard bone screw) Carroll-Girard Suitable for displaced zygomatic fracture with high Stability after reduction 17 17 Methods of reduction Buccal sulcus Buccal approach (Keen 1909) 1909) Elevation from Elevation eyebrow approach eyebrow (the same principle of Gillies (the approach) approach) 18 18 Open reduction and fixation Transosseous wiring at – Frontozygomatic suture – Infraorbial rim Surgery: •Lateral eyebrow incision •Infraorbital approach 19 19 Open reduction and fixation Rigid fixation using plate and screws at Frontozygomatic suture Infraorbial rim Inferior buttress of the zygoma Surgery: •Lateral eyebrow incision •Infraorbial approach •Subciliary (blepharoplasty) incision •Mid-lower lid incision •Transconjunctival approach 20 20 Points of fixation: Lateral orbital rim Buttress of zygoma Infraorbital rim and buttress 21 21 Other methods of fixation Kirschener wire Pin fixation Antral pack 22 22 Internal orbital fractures In conjunction with other In facial fractures facial As isolated type (Blow out As fracture) fracture) 23 23 Anatomy The floor is made of: Maxillary bone and part of zygoma bounded laterally by the inferior orbital fissure and small part of the ethmoid bone bone 24 24 Clinical and radiographical presentation Subconjunctival ecchymosis Crepitation from air emphysema Displacement of palpebral fissure Unequal pupillary levels Diplopia enophthalmos 25 25 Diplopia and Diplopia enophthalmous enophthalmous Superior orbital Superior fissure syndrome fissure 26 26 Treatment Treatment Rational for intervention: Rational Small defect with no clinical consequence Small may not warrant the surgical intervention. may Large defect with handicapping symptoms Large should be operated. should 27 27 Method of reconstruction Intra-sinus approach Intra-sinus to the orbital floor to External approach to External the internal orbital floor floor 28 28 Materials in orbital reconstruction Autologous graft Bone (cranial, rib, iliac) Bone Cartilage Cartilage Allogenic materials Lyophilized dura Alloplastic materials Siliastic and proplast Siliastic implants implants Teflon hydroxyapatite Titanium mish 29 29 Nasal-orbital ethmoid injuries They represent a wide spectrum of injuries Simple nasal fracture with involvement Of orbital bones Grossly comminuted and compound naso-orbital ethmoid fracture involving the base of skull with significant displacement 30 30 Diagnosis Diagnosis Clinical examination: Clinical Obliterating swelling Canthus detachment Lacrimal apparatus damage Deformity of nasal bridge CSF leak Radiographical examination: Occipitomental views Lateral skull views CT and 3D CT 31 31 Fracture classification Nasal-orbital ethmoid fractures Type I Unilateral or bilateral, involves only one portion of the Unilateral medial orbital rim with the attached canthal tendon medial Type II Unilateral or bilateral, may be large segments of Unilateral comminuted type and the canthus remains attached to the large central segment to Type III Unilateral or bilateral, comminution involves the central Unilateral segment of the attached tendon results in avulsion of medial canthus of 32 32 Management of nasal-orbital Management ethmoid fractures ethmoid Examination for Examination determination of the extent of the injury (surgical exploration) exploration) Nasal bone Orbital and ethmoidal Frontal bone Debridement and closure of Debridement open wounds open Reduction and stabilization of bone fracture of 33 33 Principles of treatment Good surgical exposure via: Existing laceration Coronal flap Open sky approach Reduction and stabilization using: Transnasal wiring Osteosynthesis Prompt treatment as an aid to good reduction reduction Immediate bone grafting if this is Immediate indicated indicated 34 34 Detached canthus Traumatic telecanthus Increase in inter-canthal distance Increase secondary to canthus displacement or detachment detachment Seen in association to: Nasal bone NEO Le Forts fractures 35 35 Surgical management of detached Surgical canthus canthus Transnasal wiring Transnasal technique (unilateral type) type) Canthopexy Canthopexy – Identification of the Identification ligament ligament – Liberation of the Liberation periorbital tissue periorbital – Liberation of the lacrimal Liberation pathway pathway – Nasal transfixation – Contralateral fixation 36 36 Lacrimal duct system injury The lacrimal sac can be torn by The fragments of a comminuted fracture fragments Or Compressed by a mass of callus Compressed which may block the nasolacrimal canal which EPIPHORA EPIPHORA Dacryocystitis Dacryocystitis 37 37 Reconstitution of the lacrimal passages Done at the same time of canthopexy via – – – The original scars Lateral nasal incision (Lynch) Lateral Bi-coronal incision Dacryocystorhinostomy Dacryocystorhinostomy If the sac remains intact, drainage of lacrimal fluid by probing or removing of surrounded bone to allow drainage into the nose nose Conjunctivo-rhinostomy implantation of a duct-like polythene tube or glass in case of implantation duct damage duct 38 38 Frontal sinus fracture Frontal sinus An air filled cavity lined by ciliated respiratory epithelium encased in the frontal bone Drains into nasal cavity via fronto-nasal duct 39 39 Extent of the injury: Anterior table Posterior table Associated injuries: Associated mid-face or head injuries e.g. injuries Le Fort II, III NOE Neuralgic insults Ocular injuries 40 40 Diagnosis Diagnosis Clinical examination Clinical Radiographical Radiographical evaluation evaluation Occipitomental views Lateral skull view CT scan 41 41 Classification of fractures Anterior table fracture – Linear – Displaced Posterior table fracture – Linear – Displaced Outflow tract injury (naso-lacrimal duct) (naso-lacrimal Outflow 42 42 Surgical management Surgical Intranasal cannulation Intranasal Frontal sinus Frontal trephination trephination Osteoplastic flap Osteoplastic Sinus ablation (obliteration) (obliteration) Cranialization Cranialization Reduction and fixation Reduction 43 43 Reduction and fixation Surgical approaches: – Site of penetrating injury – Coronal approach 44 44 Sinus ablation Sinus (obliteration) (obliteration) – Bone – Fat – Muscle and Muscle fascia fascia – Alloplastic Alloplastic materials materials 45 45 Fixation – Wires – Plating 46 46 Nasal fractures Anatomy Midline central facial Midline structure that fulfills both cosmetic and functional purposes functional Formed by union of Formed rigid and flexible struts rigid 2 rectangle-shaped rectangle-shaped nasal bone nasal ULCs, LLCs and ULCs, midline septal cartilage cartilage 47 47 Classification of injuries Low energy injuries Simple injury caused by low velocity trauma (simple Simple noncomminuted) noncomminuted) High energy injuries Severe injury with comminution of nasal facial Skelton due to Severe higher amount of energy higher Patterns of injury •Lateral injury (from the side) •Sagittal injury (from the front) •Inferior injury (from below) 48 48 Treatment Treatment Low energy injuries Low Reduction (close Reduction manipulation, open reduction) and stabilization reduction) Nasal packing External nasal splint Adjunct septoplasty Postoperative care 49 49 Complex injuries Immediate measures: Extra and intranasal examination Identification of extra and intranasal Identification lacerations lacerations Identification and control of site Identification bleeding bleeding Surgical procedures: Open septal procedures Open nasal procedures Open rhinoplasty Open-sky “H” technique 50 50 ...
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This note was uploaded on 11/10/2011 for the course PDBIO 220 taught by Professor Tomco during the Winter '09 term at BYU.

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