Maxillofacial trauma . They are soft tissue lesions without cutaneous continuity solution. They are accompanied by pain, bruising, bruising and, in the most severe cases, skin necrosis. They may not require treatment or require mandatory drainage, especially with regard to bruising of the nasal septum and the pinna.
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- 1 Fractures of the middle third of the facial skeleton
- 1 Nasal fractures
- 2 The conduct to follow
- 3 To effect both fracture reduction and tamponade
- 4 Fracture of the zygomatic arch
- 5 The conduct to follow
- 6 Malar bone fractures
- 7 The conduct to be followed in the early stages of treatment and evacuation will be:
- 8 Lefort-type fracture
- 9 In the medical position of the battalion the conduct to be followed will be:
- 10 In the medical post of the regiment the conduct to be followed will be:
- 11 In the sanitary medical battalion, a detailed examination will be made to detect associated injuries and measures will be taken to:
- 2 Mandibular Fractures
- 1 In order to carry out the inspection, it is necessary to have lighting that facilitates the endo-oral examination through which the following can be found:
- 2 In the battalion medical post:
- 3 The steps for its realization are the following:
- 4 For the placement of the vestibular arches, proceed as follows:
- 3 Sources
Fractures of the middle third of the facial skeleton
The skeleton of the middle third of the face is superficially framed between two horizontal and parallel lines that pass one through the eyebrow and the other through the lip corners. The increase in motorized transport of troops and the power of artillery has caused the fracture of this region to be frequent in modern warfare.
To facilitate their study, they are divided into: nasal fractures , zygomatic arch fractures, malar bone fractures and Lefort-type fractures. Of the different fractures that occur in this region only one, those of the zygomatic arch have the possibility of being closed, since the others have their open condition implicit, since the bone framework of the middle third of the face houses multiple cavities covered by the respiratory mucosa, which is injured at the slightest displacement of the bones .
Fractures of the middle third of the facial skeleton may or may not affect dental occlusion. They are not affected by nasal fractures, those of the zygomatic arch and those of the malar bone . The Lefort type affects it to a variable degree.
They are caused by direct trauma, which if it is in the antero-posterior direction determines a crushing of the nasal pyramid, while if it is in the lateral direction, it deflects it towards the opposite side to that of the application of force. The deformity is followed by heavy bleeding (epistaxis), which is caused by tearing of the nasal mucosa when displaced fractured bones that are closely related to it.
The diagnosis is based on the data obtained through questioning, but mainly during the physical examination: deviation or crushing of the nose , epistaxis, crepitus and pain on palpation.
The conduct to follow
- Apply the measures to preserve the life of the injured, which includes hemostasis due to anterior nasal packing.
- Perform tetanus and infection prophylaxis, which includes the administration of 1 million units of penicillin intramuscularly.
- Relieve pain using 1g of dipyrone intramuscularly.
- Prepare the injured person for evacuation as a second priority, sitting in a medical transport.
If there are no associated injuries, nasal fractures should be reduced in the medical health battalion. With the aim of hemostasis and keeping the bones in place, once the bone fragments have been dealt with, an anterior nasal tamponade is performed.
To effect both fracture reduction and tamponade
- 1% novocaine infiltration to block the nasal pyramid.
- Introduction through a nostril of a straight hemostat, protected with gauze. While pulling with one hand to lift the bones , the other adjusts the bones and shapes the nose.
- Also perform the same maneuver on the other side, if necessary, until the nose has recovered its normal appearance.
- Proceed to tamponade with Vaseline handle through both nostrils simultaneously.
Subsequently, the injured will be prepared for evacuation in third priority, sitting in a medical transport.
Zygomatic Arch Fracture
The zygomatic arch is a structure located on the lateral limit, between the skull and the face. Given its configuration, it is susceptible to fracture due to direct trauma that affects it, sinking it. The fractured fragments stand in the way of the coronoid process of the jaw, which prevents the injured person from opening the mouth. Exceptionally, an open fracture of this structure occurs.
The diagnosis will be based on the history, which will provide valuable data such as: magnitude and direction of the trauma; time elapsed since the injured suffered the injury and difficulty or inability to open the mouth. The physical examination will allow observation of the crushing of the region when the injury is recent, but this will not happen when the edema has already been established. You can also check the degree of difficulty in opening the mouth or the limitation to perform the deduction movements. By palpation it is possible to see if there is discontinuity in the bone surface, in which case it will cause pain.
The conduct to follow
- Relieve pain by administering analgesic orally.
- Prepare the injured for evacuation as a third priority, sitting in a medical transport
Surgical treatment must be performed at the hospital base.
Malar bone fractures
The prominent position of this bone exposes it to suffer fractures due to the most varied trauma. Its proximity to the maxillary sinus determines that the fracture damages the mucosa of the maxillary sinus and thus communicates with the exterior. Injuries to the mucosa of the maxillary sinus cause bleeding to flow outside through the ostium and the nasal window on the affected side.
It is common for the fracture line to be of interest to the infraorbital foramen and for the bony edges to cause injury to the vessels and nerves that pass through it, which explains the appearance of palpebral ecchymosis and paresthesia of the hemilabe, wing of the nose. and corresponding cheek. The dipoplia (double vision) manifested by some injured is due to the descent of the eyeball due to a comminuted fracture of the floor of the orbit and the loss of the external insertion of the ligaments that support the eye.
The diagnosis is required through questioning. In addition to violence and traumatic force management, other symptoms such as pain, paraesthesia, diplopia, and unilateral epistaxis are manifested. The physical examination will allow to appreciate the magnitude and characteristics of the injury. First, flattening of the cheekbone and eyelid ecchymosis can be seen (in recent trauma). When the latter affects the conjunctiva, it acquires greater diagnostic value. Palpation of the orbital rim will reveal frequent deformation of the bony plane (step) in the middle third of the lower rim.
The conduct to be followed in the early stages of treatment and evacuation will be:
- Control bleeding by anterior nasal tamponade.
- Relieve pain by administering 1g of dipyrone intramuscularly.
- Prepare the injured person for evacuation as a second priority, lying down on medical transport.
All malar bone fractures will receive specific treatment at the hospital base.
In severe trauma to the face, when the face is projected forward against a hard surface or when a hard object strikes in the anterior-posterior direction, very complex fractures occur at different levels of the middle third of the facial mass. When the fracture line is low and passes over the apices of the upper teeth, but below the maxillary sinuses, the upper arch is supported only by the mucosa (floating fracture or Lefort I type).
On other occasions, the fracture line passes through the maxillary sinuses, the nostrils, and backwards, the lower end of the pterygoid process comes to be of interest, so that a free central block remains pyramidal in shape (Lefort II type fracture). Lesions of the nasal mucosa and maxillary sinuses produce a profuse epistaxis, which aggravates the respiratory compromise, which may be caused by the fall of the soft palate as a consequence of the fracture at the level of the pterygoid.
Other times, high fractures occur that separate the facial skeleton from the skull (Lefort III fracture), as it passes through both orbits and nostrils and reaches deep into the base of the pterygoid process. The fall of the veil of the palate against the back of the tongue is very frequent in these injured and, therefore, respiratory compromise.
The lower traction exerted by the pterygoid muscles, in addition to promoting the dropping of the soft palate, produces premature contact of the molars and an anterior open bite or adachia.
In many occasions the cribriform plate of the ethmoid is injured, which explains the exit of cerebrospinal fluid through the bloody nostrils (rhinorrhea). The diagnosis will begin to be established through questioning, which will be limited by the state of gravity of the injured person, but can provide information on the type of accident and the direction of the trauma.
The physical examination will provide numerous signs of these fractures, such as: the elongated face seen by the skull- facial separation , the epistaxis accompanied by cerebrospinal fluid, the anterior adachia and the ecchymosis in glasses. In these injured there may be a respiratory compromise, not only due to the dropping of the soft palate, but also due to the aspiration of blood from the nasal mucosa, which explains the resistance offered by these injured to staying supine.
In this eventuality, the palate should be pulled with the index finger and the injured person placed in the prone position, which improves breathing. The bimanual examination must specify the level of the fracture, for which the head is held fixed with the left hand, while the jaws are held between the index and thumb fingers of the right hand.
The behavior to be followed during the first hours after the trauma will consist of a close observation of the injured, due to the possibility of a respiratory compromise or a cranioencephalic injury becoming evident.
In the battalion’s medical post, the conduct to be followed will be:
- Apply life-saving measures, including anterior traction of the palate, in case of respiratory compromise and the position of the injured person in prone position.
- Prophylaxis of tetanus and infection, which includes the administration of one million units of penicillin intramuscularly.
- Administer 1g of dipyrone intramuscularly to ease pain.
- Prepare the injured person for evacuation in first priority, on a stretcher in prone position and in an ambulance.
In the medical post of the regiment the conduct to be followed will be:
- Apply life-saving measures, including performing a tracheostomy if there is respiratory compromise.
- Perform prophylaxis of the infection by administering penicillin intramuscularly.
- Administration of 1g of dipyrone intramuscularly to claim pain.
- Prepare the injured person for evacuation in first priority, on a stretcher, supine and in an ambulance.
In the sanitary medical battalion, a thorough examination will be made to detect associated injuries and measures will be taken to:
- Conserve life
- Avoid infection
- Soothe pain
- Prepare the injured person for evacuation in first priority on a stretcher, supine and in an ambulance.
The lives of these injured are threatened firstly by respiratory compromise, secondly by neurological complications, and thirdly by traumatic shock, and it is precisely this that must be borne in mind in front of them at all stages of treatment and evacuation.
Despite a solid constitution, the jaw is frequently injured during combative actions due to the effects of firearms and trauma in traffic accidents. Most of the mandibular fractures are open to the outside or the oral environment through direct communication through the dental alveoli. It is only possible to speak of closed fractures when, in the absence of injury to the overlying soft tissues and the external auditory canal, the location is in the ascending branch or in the mandibular condyle.
It should be remembered that regardless of the location, the type of fracture will always be easier to diagnose and treat if the injured person retains his teeth, since they will serve as a point of reference to appreciate displacement and as anchoring elements for immobilization. In these fractures the pain is exacerbated by chewing and even by speaking, due to injury to the lower dental nerve.
The facial contour deformity is caused by the displacement of the fragments or by the edema following the trauma. The ecchymosis of the alveololingual sulcus and the gingiva at this level occurs because when the fractured ends move towards the midline, they damage the subperiosteal blood vessels.
The adachia and the deviation from the midline (dental malocclusion) that are present in most of these injuries are due to the conjugation of two factors: the direction of the fracture line and the action of the chewing muscles (masseter, temporal and pterygoid) The force resulting from the action of the chewing muscles pulls the posterior fragment upwards and inwards, from which it appears that when the fracture line is favorable, the bone ends tend to approach while when it is favorable they tend to separate.
The diagnosis will be established through anamnesis and physical examination. The history of the injury will provide important data regarding the nature and magnitude of the trauma and the physical examination will provide sufficient elements to establish the diagnosis and even to determine whether it is a favorable or unfavorable fracture.
To carry out the inspection, it is necessary to have lighting that facilitates the endo-oral examination through which the following can be found:
1 – In favorable fractures:
A – An equimotic area of the lingual (internal) gingiva that is sometimes the only sign of fracture that can be obtained by inspection. B – Other elements such as localized edema, vestibular equimotic areas, wounds and that will guide the location of a fracture, which must be specified by bimanual palpation.
2 – In unfavorable fractures:
- Discontinuity of the dental arch due to deviation towards the midline of the posterior segment.
- Occlusal plane step due to elevation of the posterior segment and relative decrease of the anterior segment.
- Gingiva tears that allow direct observation of the fracture.
- Adachia anterior, appreciable when the wounded man is told to try to contact his teeth.
- Deviation of the mandibular midline towards the fracture side (note the continuity of the upper midline and lower midline).
Two-hand palpation will allow diagnosing favorable fractures not evident during the inspection and evaluating unfavorable fractures. It is recommended to start by inserting the index finger pads into the injured person’s external ear canals and instructing the injured person to open and close the mouth. Thus, the absence of condylar movement, crepitation and pain in condylar fractures can be verified.
The index fingers are then slid along the mandibular border, from back to front, to detect bone defects (step) or stabbing pain that, together, will show the location of the fracture.
After finishing the previous step, with the index and thumb fingers of both hands, the jaw is held at two points: retromolar space and canine region on the same side and pressure is applied with each hand (one in the opposite direction of the other), with which abnormal movement, crackling and pain will occur when there is a fracture at this level. These maneuvers will be performed twice more, once in both canine regions and the other in the opposite region and retromolar space. The behavior to be followed in the early stages of treatment and evacuation, regardless of the type and location of the fracture.
At the battalion medical post:
- Apply measures to preserve the life of the injured. Previous fixation of the tongue will be made if necessary.
- Prophylaxis of tetanus and infection.
- Inject one million units of penicillin intramuscularly
- Administer 1g of dipyrone intramuscularly to claim pain
- Review and adjust immobilization performed on the battlefield
- Provide a liquid diet if the injured person must swallow.
- Prepare the injured for evacuation in the second at the hospital base)
- Perform infection prevention and pain control.
- Carry out a thorough examination of the injured in order to decide whether to evacuate directly or to immobilize the fracture previously. In the latter case, and depending on the time available for its realization, the interdental fixation technique with wire grommets or the fixation with vestibular arches can be chosen.
Interdental fixation with wire grommets has the advantage that it can be carried out in a short time and requires only number 28 stainless steel wire and instruments to place it.
The steps for its realization are the following:
- Take a 3cm segment of wire, bend it in a U shape, pass the ends through an interdental space, from outside to inside.
- Return one end outward through the interdental space distal to the one chosen to start and the other end through the mesial intermediate space.
- Pass the end of the distal wire through the U-handle forward.
- Twist the two ends of the wire without much tension. Then turn the U-handle 3 or 4 times to adjust the wire to the tooth necks and finish twisting the ends of the wire until it is immobilized, which is verified by pulling it prudently.
- Carry out identical steps on two teeth that are antagonistic to the fixed ones. Two other handles are placed on the opposite side.
- Bring the jaw to the occlusion position and fix it with a wire until the injured person cannot perform mandibular movements and is comfortable.
This technique has the disadvantage of not being very rigid and that only eight teeth participate as fixation elements. The fixation with vestibular arches requires more time and resources than the previous one; however, its advantages in terms of stability and resistance justify the effort, whenever the volume of work allows it. The indispensable materials for its placement are: prefabricated malleable vestibular arches, stainless steel wire number 28 and rubber elastic band, of those used in orthodontics.
To place the vestibular arches, proceed as follows:
- Take a segment of malleable arch and adapt it to the necks of the upper teeth, from one second molar to the other.
- Pass wires around the neck of each tooth, so that each one includes the neck of the tooth and the vestibular arch.
- Twist the ends of each wire to secure the ferrule to the teeth.
- Place two segments of the vestibular arches in the lower dental arch, one in front and one behind the fracture site, in the same way as it was done in the upper teeth, but after local anesthesia.
- Once the vestibular teeth are fixed, place elastic bands between them to fix the jaw. After the jaw is fixed, the injured person may be given a liquid diet and prepared for evacuation as a third priority, except for those with cutaneous wounds with exposed fractures, which will be evacuated in the first order.