THE GENERAL METHOD FOR A MAXILLOFACIAL INJURY

This extends Section 51.3 on the care of a severely injured patient. Injuries to his lower jaw are described i n Section 62.7.

IMMEDIATE TREATMENT

CAN THE PATIENT BREATHE? If his breathing is difficult, look into his mouth to see if: (1) his airway has been obstructed by blood and vomit, (2) his soft palate has been driven down onto his tongue by displaced Le Fort fractures, or if, (3) his tongue has fallen backwards after a mandibular fracture?

If his soft palate has been driven onto his tongue, hook your fingers round the back of his hard palate, and pull the bones of the middle of his face gently upwards and forwards, so as to restore his airway and perhaps the circulation to his eyes. Reduction may not be easy, and you may need considerable force. If the fracture is impacted and you fail to reduce it, he may need a tracheostomy, as described below.

If necessary, grip his maxillary alveolus with the special forceps (Rowe’s) for this purpose, or with suitable strong sharp toothed forceps, and rock it to disimpact the fragments.

If his tongue or lower jaw has fallen backwards, put some sutures or a towel clip through it, and gently pull it forwards. Lying him on his side will also help. When you transport him, lie him on his side.

If he has a severe jaw injury with much tissue loss, transport him lying on his front with his head over the end of the stretcher and his forehead supported by bandages between its handles, as in Fig. 62-4.

If he feels more comfortable sitting up, let him do so. His airway may improve remarkably when he does this.

Suck out his mouth, remove blood clots, debris, loose teeth, vomit, and foreign bodies.

A Guedel airway does not help, so don’t waste time trying to insert one. Tracheal intubation is usually impractical.

If his nose is severely injured and bleeding, suck it clear and insert a nasopharyngeal tube, or any similar thick rubber tube, down one side. Put a safety pin through it to stop it slipping, as in A, Fig. 62-2.

CAUTION! A nasopharyngeal tube does not always ensure a clear airway because it may kink or block against the posterior pharyngeal wall, so watch it carefully and twist and adjust it as necessary. Keep it sucked out by passing a smaller tube down it, attached to a sucker. Use the same equipment to suck out the patient’s mouth, and keep it beside his bed.

Tracheostomy. You may need to do a tracheostomy (52.2) if: (1) You cannot disimpact and reduce the fracture of the middle third of a patient’s face. (2) You cannot control severe posterior bleeding. (3) He has oedema of his glottis, particularly following a neck injury. (4) He has a severe injury with much tissue loss. Tracheostomy will be difficult. Use ketamine, local anaesthesia and a cuffed tube.

CAUTION! If his breathing is in danger and you have to refer him, he will be safer with a tracheostomy than with a suture through his tongue to pull it forward, which is the other alternative.

STOP BLEEDING Tie any large bleeding vessels. If there is troublesome oozing, apply an adrenaline soaked pack firmly to the bleeding surface. A postnasal pack (Chapter 24) will usually stop bleeding. If necessary, use large temporary haemostatic sutures (3.1), but take care not to strangle the tissues.

If a wound is deep, be prepared to pack it. Occasionally, you may have to tie a patient’s external carotid artery (3.5).

SHOCK is unusual. If a patient is shocked, suspect that he also has an abdominal or a thoracic injury.

THE HISTORY AND EXAMINATION OF A MAXILLOFACIAL INJURY

The patient is probably unable to talk, so enquire from observers if he lost consciousness and so might have a head injury (63.1).

Gently wash his face with warm water to remove caked blood. Look at it carefully for asymmetry. Compare one side with the other throughout the examination. Is his nose or his face flattened? If you suspect a fracture of his zygoma, look at it from above and below and use the two pencil test in Fig. 62-12.

BRUISING This is a useful guide to underlying injuries.

Zygomatic fractures There is always bruising round the patient’s orbits, which develops rapidly as a uniform continuous sheet. It is limited peripherally by the attachments of his orbicularis muscle, and extends subconjunctivally towards his eye from the lateral side. Ask him to look inwards You will see bruising extending back into his orbit without a posterior limit.

Look inside his mouth and examine his upper buccal sulcus for bruising, tenderness, and crepitation over his zygomatic buttresses.

Nasal fractures There is bruising round his orbits which is most severe medially.

Black eye This is the main differential diagnosis. Orbita bruising is most severe medially. It is subconjunctival, patchy, and bright red.

EYES Has either of the patient’s eyes sunk inwards or downwards? Are they level? Displacement may indicate herniation of the contents of his orbit through its floor into his maxillary sinus, or a fracture at the fronto–zygomatic suture line.

Separate his eyelids, and test the sight of each of his eyes separately. If an eye is blind, its optic nerve may be injured. Ask him to follow your finger as you test for diplopia. This may be due to: (1) displacement of his orbit, (2) displacement of his globe, (3) a 6th nerve palsy, or (4) oedema. If his eye is unable to look upwards, its inferior rectus is trapped, and his orbital floor is probably fractured. Note the size of his pupils and their reaction to light.

If he has massive proptosis, he has a retrobulbar haemorrhage which may be compressing his optic nerve. Make a small incision at his outer canthus, take a haemostat and push this into the incision (B, Fig. 62-5); blood will squirt out. If you don’t do this, his eye will become blind.

FRACTURES OF THE FACE AND SKULL Carefully feel all over the patient’s head and face for tenderness, step deformities, irregularity, or crepitus. Feel his zygomatic bones, the edges of his orbits, his palate, and the bones of his nose. In a Le Fort Type Two or Three fracture you will feel many small bony fragments under the skin in his ethmoid region.

Hold the root of his nose between your finger and thumb. At the same time put two fingers from your other hand into his mouth. If you can move his facial skeleton on his skull, he has a Le Fort fracture. You may feel it move more easily if you hold his upper gum between your thumb and index finger.

Can he open and shut his mouth, bite normally, move his jaw from side to side and protrude it? Do his teeth meet normally? If his bite is abnormal, one or both of his jaws have been fractured. Failure to move his jaw normally may indicate a displaced fracture of his zygoma or his mandible.

Examine the mucosa of both his jaws for bruising, tenderness, irregularity, and crepitus.

NERVE INJURIES Test for anaesthesia of his cheeks (infraorbital nerves) and upper gums (superior dental nerves).

TOOTH INJURIES Feel his teeth and try to rock them. Individual teeth may move abnormally, so may several adjacent teeth. Mobile teeth can be caused by: (1) A fracture. (2) Exposure of their roots. (3) Periodontal disease.

Inspect his teeth with a mirror and probe. Tap them; if they give a cracked cup’ sound, the bone above them may be fractured. If a piece of tooth is missing, X-ray the patient’s chest in case he has inhaled it.

NOSE INJURIES Epistaxis is usually unilateral or absent in zygomatic fractures, and bilateral in nasal ones. Examine the patient’s nasal septum with a speculum. This may be displaced in a nasal fracture. However, it is often asymmetrical in otherwise normal people. If he has a haematoma of the septum, it needs evacuating, goto 61.4.

LEAKING CSF may be anterior or posterior, and is usually diagnosed after a few days when bleeding and oedema have subsided. The patient may complain of a salty taste in his mouth. If you are uncertain if a discharge is CSF or not, test it as in Section 63.12. CSF may leak in severe naso–ethmoidal ractures and in some Le Fort fractures.

OTHER INJURIES Look for these (51.3), and especially for a head injury (63.1), or an injury to the patient’s cervical spine (64.3). These may be more serious than those of his face. A maxillofacial injury does not usually cause shock, so if he is shocked, suspect some other injury, especially an abdominal one, which may take priority.

X–RAYS are difficult to interpret, and involve turning the patient into a position which may obstruct his airway. Ask for: (1) An AP view of his mandible. (2) A Waters view of his skull in which you maybe able to recognise: (a) filling of his maxillary antra, and (b) irregularities in the outlines of his orbits showing they have been fractured.

WOUND TOILET AND CLOSURE AFTER A MAXILLOFACIAL INJURY

This must be thorough, especially if sand or tar are ingrained In the patient’s wounds. If you don’t remove them, severe fibrosis and disfigurement will follow. You will find a sterile toothbrush useful.

Handle his tissues gently with skin hooks and fine forceps. Remove soiled tags of deeper tissues and mucosa with scissors. Trim only 1 or 2 mm of skin edge to provide non–bevelled uncontaminated skin edges which you can approximate accurately. Use a sharp No. 15 blade and ophthalmic scissors. Close his mucosa with 310 silk, or failing this with fine chromic catgut. Close his skin by primary suture after you have fixed any fractures. If necessary, you can undermine the skin of his face for 2 to 3 cm to assist closure.

If part of the patient’s cheek Is missing, refer him immediately for primary reconstruction. If this is impractical, stitch his buccal mucosa to his skin (61-4). If necessary, do the same with his nose.

If there are loose bone fragments, conserve them unless they are grossly soiled. You can sterilize detached fragments in boiling water and replace them as chip grafts.

CAUTION! (1) Don’t close his skin under tension. (2) Don’t leave bone bare—try to cover all bony surfaces.

REDUCING FRACTURES AFTER A MAXILLOFACIAL INJURY

Reduce and, where necessary, fix any fractures of the patient’s nose (62.4), zygoma (62.5), and mandible (62.7). These are not urgent operations, so resuscitate him first. For anaesthesia, see A 6.4, and A 16.10. You can do most operations on an injured jaw using pterygopalatine blocks, bilaterally if necessary.

CAUTION! Always protect a patient’s eyes when you operate on his face.

If he has a Lie Fort fracture, or an orbital floor fracture, refer him. If you cannot refer him, the next section (62.2) describes some methods you may be able to use.

NURSING A MAXILLOFACIAL INJURY

If the patient is conscious, sit him well forward, so that his tongue falls forward, and blood and saliva can dribble out of his mouth. This will make him comfortable and also help him to breathe.

If he is unconscious, turn him onto his side into the recovery position (51-2), so that blood and saliva can run out of his nose and mouth. If other injuries prevent this, put a pillow under one shoulder, and turn his head to the other side.

FOOD AND FLUIDS If the patient is to be operated on, withhold these. Otherwise feed him through a tube.

CLEANING AND DISINFECTION is critically important for the healing of all wounds inside a patient’s mouth. Ask him to rinse out his mouth after eating, using :(1) a rinse containing 10 ml of 0.5% chlorhexidine, or (2) 2% salt solution, or failing either of these, (3) plain water. As soon as possible, encourage him to clean his teeth regularly with a toothbrush or a clean chewing stick.

Coat his lips liberally with vaseline to stop them sticking together and interfering with his respiration.

DRUGS FOR A MAXILLOFACIAL INJURY

Give the patient amoxycillin, ampicillin, or fortified procaine penicillin for one week. Start immediately (2.7). This usually prevents bone infection, and is important if a fracture opens into his mouth.

If his CSF is leaking, give him 1 g of sulphadimidine 6 hourly until 48 hours after it has stopped. Most leaks stop spontaneously, except in severely comminuted fractures.

CAUTION! Don’t give him powerful analgesics, such as morphine, which will depress his cough reflex. If he is restless, give him paradelyde or diazepam.

Don’t forget tetanus prophylaxis (54.11).

CHARTS Start a head injury chart (63-4) and a fluid balance chart (A 15-5).

FURTHER MANAGEMENT OF A MAXILLOFACIAL INJURY

If possible, refer all more serious injuries. Read on for injuries to a patient’s teeth and alveoli (62.2), simpler methods for maxillary fractures (62.3), fractures of the patient’s nose (62.4), fractures of his zygomatic complex (62.5), dislocation of his jaw (62.6), the general method for a dislocated lower jaw (62.7), fractured condyles (62.8), fractures of the ascending ramus of his mandible (62.9), fractures of the angle and body of his mandible (62.10), difficulties with mandibular fractures (62.11), and fixing mandibular fractures with acrylic resin (62.8).

TRANSPORT MAXILLOFACIAL INJURIES PRONE OR LYING ON THEIR SIDES