mandible fracture 01 31 08
TRANSCRIPT
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Thursday Morning Conference01/31/2008
Paul K. Holden, MD
UC IrvineUC IrvineOtolaryngology-Head & Neck Otolaryngology-Head & Neck
SurgerySurgery
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Case PresentationCase Presentation
You are called to assess a patient in the trauma bay s/p fall from motorcycle onto his face.
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Exam FindingsExam Findings
ABC – talking, slurred speech, hemodynamically stable.
Extensive degloving chin laceration communicates with oral cavity. Some dental step-off, obvious malocclusion.
No neck swelling or soft tissue injury.
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Additional Concerns?Additional Concerns?
Intoxication? Head Injury?
C-spine
“Open” fracture
Missing teeth? WHERE ARE THEY?
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Rest of ExamRest of Exam
PERRL/EOMi, no raccoon eyesMidface Stable, no septal hematoma, no
step-offs in midfaceFresh blood occluding EACs bilaterallyMalocclusion, 1.5 cm MICD due to painEcchymosis under tongue with minimal
retrodisplacement. FOL – airway clear.
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Studies DoneStudies Done
CT Head w/o contrast (very limited view)CT Face Axial/Coronal w/ 3-d recons
Prefer preoperative mandible series with panorex…why?
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Mandible FractureMandible Fracture
Very often more than one fracture present
May result in airway compromise (acute or delayed)
Elevated risk of c-spine injury
Almost always considered contaminated
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Immediate ManagementImmediate Management
Rule out other significant injury including brain and c-spine
Monitor for airway issues – repeat exam (may include FOL), monitored bed
Start antibiotics immediately (what type?)Pain managementDocument CN function (esp inf alveolar)
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Considerations In Mandible Considerations In Mandible FxFx
Much of the morbidity of these injuries is attributed to improper management.
Infection risk increases with passage of time, substantially higher after 72h.
Risks of nonunion, malunion, malocclusion, plate fracture, plate extrusion, TMJ fixation, jaw restriction, poor cosmetic outcome
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Steps to Avoid ProblemsSteps to Avoid Problems
Proper diagnosisConsider Co-morbid ConditionsConsider Patient Personality/OccupationProper management plan for the
circumstancesProper technique (MMF, bending, drilling,
screw placement, nerves, tooth roots)When in doubt, use a LARGER plate.
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Concepts in ReductionConcepts in Reduction
Patient’s baseline occlusion is first priority.Class I, II, III … Crossbite?Observe wear facetsDo not force class I if it doesn’t line up with
wear facets.Verify occlusion at beginning, mid, end of
case. Remove MMF to verify if necessary.
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Plate TypesPlate Types
What is…– A tension band?– A compression plate?– A lag screw?– A recon (UF) plate?– A locking plate?– Load sharing vs. load bearing plate?
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Know Champy LinesKnow Champy Lines
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Fracture TypesFracture Types
Condylar / SubcondylarRamusAngleBodyParasymphasealSymphasealAlveolar Ridge
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Type and ManagementType and Management
Symphaseal 2.0 L Compression + TB Lag Screws
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Type and ManagementType and Management
Comminuted Symphaseal 2.4 Locking Recon Plate + TBLeft Subcondylar
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Type and ManagementType and Management
Parasymphaseal Two Miniplates?
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Type and ManagementType and Management
Comminuted Parasymphaseal 2.4 Locking Recon Plate with TB
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Type and ManagementType and Management
Comminuted Body/Parasymph 2.4 Locking Recon Plate with MPs
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Type and ManagementType and Management
Symphaseal and Angle, 3rd Molar Single Champy MP at Angle
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Type and ManagementType and Management
Disloc Angle w/ Basal Triangle 2.4 Locking Recon Plate with 2.0 MP
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Special CaseSpecial Case
Edentulous Body Fracture 2.4 Locking Recon Plate, 4 screws
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Another Special CaseAnother Special Case
Infected Angle Fracture 2.4 Locking Recon Plate
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Other Special CasesOther Special Cases
Bilateral Parasymphaseal – Geniohyoid origin lost, tongue prolapses into airway.
Bilateral subcondylar – prone to TMD, loss of height, retrusion and increased width of mandible.
Pediatric Fractures – remove plates or use absorbable, minimize MMF.
Loss of Bone – from infection, severe trauma or nonunion.
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Controversies/DifficultiesControversies/Difficulties
When to perform ORIF on subcondylarTooth in the fracture lineStops for unilateral subcondylarMissing Teeth (but not edentulous)When to go extra-oral routeHow long to continue abx postop (Ali?)
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Back to Our PatientBack to Our Patient
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
Back to Our PatientBack to Our Patient
Comminuted Symphaseal
High right subcondylar fracture/dislocation
Non-displaced left subcondylar fracture
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
U.C. Irvine - Otolaryngology-Head & Neck
Surgery
No Mas!No Mas!