Fractures Of Bone
- Midline: Fractures between central incisors.
- Symphysis: Fractures occurring within the area of symphysis.
- Parasymphysis: Bounded by vertical lines distal to canine teeth.
- Body: From distal symphysis to a line coinciding with the alveolar border of the masseter muscle usually including the third molar.
- Angle: Triangular region bounded by the anterior border of the masseter muscle to posterosuperior attachment of the masseter muscle.
- Ramus: Bounded by the superior aspect of the angle to two lines forming an apex at the sigmoid notch.
- Condylar process: Area of condylar process superior to the ramus region.
- Coronoid process: Includes coronoid process ofthe mandible superior to the ramus region.
- Dentoalveolar process: Region that would normally contain the teeth
Read And Learn More: General Surgery Questions and Answers
- Swelling at the angle externally and there may be obvious deformity.
- Laceration of skin or mucosa.
- Step deformity behind the last molar tooth may be visible which is more apparent if no teeth are present in the molar region.
- Undisplaced fractures are usually revealed by the presence of a small hematoma adjacent to the angle on either the lingual or buccal side, or both.
- Anesthesia or paraesthesia of the lower lip may present on the side of the fracture.
- Inability to close the jaw causing premature dental contact.
- Occlusion is often deranged. Movements of the mandible are painful and the range of movements is reduced.
- Trismus to some degree is usually present.
- Anterior open bite is seen in bilateral angle fracture.
- Ipsilateral open bite is seen in unilateral ankle fracture.
- Physical signs and symptoms such as swelling and bone tenderness are similar to those seen in the fracture of the angle of the mandible.
- Even slight displacement of the fracture causes derangement of the occlusion.
- Premature contact occurs on the distal fragment because of the displacing action of muscles attached to the ramus.
- Fractures between adjacent teeth tend to cause gingival tears.
- When there is gross displacement, the inferior dental artery may be torn and this can give rise to severe intraoral hemorrhage.
- Sublingual hematoma or ecchymosis in the floor of the mouth.
- The flattened appearance of the lateral aspect of the face.
- Inability to open or close the jaw.
- Crepitation on palpation.
- These fractures are commonly associated with fractures of one or both condyles.
- This fracture may be missed, if occlusion is undisturbed locally.
- The presence of bone tenderness and a small lingual hematoma may be the only physical signs.
- Sublingual hematoma or ecchymosis in the floor of the mouth.
- Posterior open bite or unilateral open bite is seen in para symphysis fracture. Posterior crossbite can result from midline symphysis fractures.
- Crepitation on palpation is noted in symphyseal fracture.
- An inability to close the jaw causes premature dental contact.
- A retruded chin can be caused by bilateral parasymphy seal fracture.
- The fracture line is often oblique which allows over-riding of the fragments with lingual inversion of the occlusion on each side.
- They are uncommon.
- The flattened appearance of the lateral aspect of the face.
- Inability to open or close the jaw.
- Swelling and ecchymosis are usually noted both extraorally and intraorally.
- Tenderness over the ramus and movements produce pain over the same area.
- Severe trismus is present.
- Fracture of Coronoid Process
- The fracture can be caused by direct trauma to the ramus but is rarely in isolation. It is usually considered to result from reflux contracture of the powerful anterior fibers of the temporalis muscle.
- This fracture is difficult to diagnose clinically.
- Tenderness over the anterior part of the ramus.
- Painful limitation of movement, especially during protrusion of the mandible may be found.
- It depends upon the line of fracture.
- Oblique fracture shows a bad prognosis.
- Spiral fracture shows a good prognosis due to increased surface area.
- Reduction
- Open reduction
- Closed reduction.
- Fixation.
- Immobilization.
- Prevention of infection and rehabilitation.
- After anesthesia is given, the dislocated fragments of the mandible are held between the fingers and thumbs on each side of the fractured line.
- The fragments are shaken up and down to disengage them or to break the fibrous union.
- When normal occlusion is achieved the fragments are fixed in position.
- Various methods used for close reduction of mandibular fracture are:
- Arch bar fiction
- Bridle wire
- The figure of 8 wiring
- Gilmer’s direct wiring
- Eyelet wiring
- Essig’s wiring
- Stout’s continuous loop wiring
- Risdon’s wiring.
- It is a procedure by which we expose the fractured bone ends and bring them into alignment under direct vision.
- The fractured bone can exposed by intraoral or extraoral approach.
- The extraoral approach is preferred to avoid contamination.
- Depending on the areas to be accessed various surgical approaches are used in open reduction.
- Symphysis, para symphysis, and the body of the mandible can be approached via intraoral incisions given in the labial mucosa. Extra-oral incisions can be used to approach these regions.
- Symphysis can be approached via an incision placed in the submental region of the skin crease. The body of the mandible can be approached by a sub-mandibular approach.
- The angle of the mandible should be approached via an intra-oral incision placed on the third molar region which extends to the anterior border ramus. Extraorally the angle of the mandible can be approached via Risdon’s incision.
- Ramus of the mandible can be approached via the retromandibular incision.
- The coronoid process can be approached via an intra-oral incision placed high on the anterior border of the ramus of the mandible.
- The Condyle of the mandible can be approached via various incisions, i.e. preauricular, retromandibular, and submandibular, etc.
- Aligned bone is held in position with the help of wire, screws, or bone plates as per requirement.
- In this phase, the fractured fragments are fied, in their normal anatomical relationship to prevent displacement and achieve proper approximate fiation.
- If a closed reduction is done, the fractured fragments are fixed and immobilized in an anatomically reduced position by means of wire which is placed around teeth, i.e. interdental wiring.
- Various wiring techniques are used and each of them is used in various types of mandibular fractures.
- Wiring techniques used are Bridle wire, Figure-of-8 wiring,
- Gilmer’s direct wiring, eyelet wiring, Essig’s wiring, stout’s continuous loop wiring, and Risdon’s wiring.
- If an open reduction is done the fiction can be:
- Non-rigid fiction: By use of transosseous wires or wire osteosynthesis
- Semi-rigid fixation: By use of monocortical mini plates or lag screws
- Rigid fixation: By use of dynamic compression plates immobilization
- In this phase, the reduced and fied fragments of bone are immobilized for a certain period for healing to occur.
- A fixation device is given to stabilize the reduced fragments into their normal anatomical position till clinical bony union takes place.
- For mandibular fracture, the period of immobilization should be 4 to 6 weeks.
- If the mandibular condyle is fractured, then a period of immobilization is for 2 to 3 weeks.
- Prevention of infection and rehabilitation
- A proper antibiotic regimen should be given to the patient to prevent intra-operative and post-operative complications.
- If there is a presence of a gap between the bony ends, a proper bone graft should be given.
- After 4 to 6 weeks as the fracture is healed, and the jaw regains some of its strength, the patient should be encouraged to be on a normal diet and use the jaw as he/she used it before the trauma.
- The fracture was not reduced properly.
- After reduction replacement occurs within the plaster for this a check X-ray after a week is advisable in certain fractures anticipating displacement, e.g.
- Fracture of both bones of the forearm.
- Growth disturbance due to injury to the epiphyseal cartilage may lead to malunion; fracture separation of an epiphysis does not lead to growth disturbance as the fracture occurs through the metaphyseal plate
- keeping the epiphyseal cartilage intact.
- Sites of malunion are those where the bone is cancellous so union occurs as a rule, but malunion complicates due to the imperfect position of the bone ends. These sites are the fractured neck and the supracondylar fracture of the humerus, collars fracture, fracture through the condyles of the tibia, etc.
Question 5. Describe briefly the General treatment of fracture of bone.
Answer. General Management of Fracture of Bone
- Early treatment (Neurovascular problems)
- The principle of management of fracture is to deal with life-saving problems fist
- This meanspayingattntiontoABC (airway, breathing, and circulation) and the neurovascular status
- Severe initial injury: This is most probably due to associated soft tissue damage which allows diffusion of hematoma and also due to the blood supply to the bone fragments.
- Infection of fracture hematoma: Healing fails because of the cellular element that is required for the production of bone at the production of pus.
- Soft tissue interposition between the fracture fragments may so separate them that it is physically impossible for them to unite.
- A poor blood supply at the fracture site.
- Inadequate immobilization: Excessive movement at the fracture site during the healing phase may produce delayed union because the fracture site is constantly ‘refractured’ by the movement.
- Compound fracture (when more than two segments) or open fracture.
- Closed or simple fracture: When the outer skin is not injured due to fracture. The fracture site does not communicate with the outer surface.
- Open or compound fracture: In this type, outer tissue is also broken down and the fracture site communicates with the outer surface.
- Comminuted fracture: When the bone is broken down into more than two segments. It shows a bad prognosis.
- Impacted fracture: When one fragment enters into another segment.
- Greenstick fracture: Only the bone is bent like a green stick.
- Fractures are incomplete and occur in children.
- Transverse, oblique, and spiral fracture.
- It depends upon the line of fracture.
- Oblique fracture shows a bad prognosis.
- Spiral fracture shows a good prognosis due to increased surface area.
- General Principles of Treatment of Fracture
- The three fundamental principles of fracture treatment are reduction, immobilization, and preservation of function, rehabilitation.
- This first principle must be qualified by the words ‘if necessary’.
- In many fractures, reduction is unnecessary, either because there is no displacement or because the displacement is immaterial
- to the final result.
- If it is judged that perfect function can be restored without undue loss of time, despite some uncorrected displacement of the fragments, there is clearly no object in striving for perfect anatomical reduction.
Indeed, meddlesome intervention may sometimes be detrimental, especially if it entails open operation.
- When reduction is decided upon it may be carried out in three ways:
- By closed manipulation
- By mechanical traction with or without manipulation
- By open operation.
Manipulative reduction
- Closed manipulation is the standard initial method of reducing the most common fractures. It is usually carried out under general anesthesia, but local or regional anesthesia is sometimes appropriate.
The technique is simply to grasp the fragments through the soft tissues, to disimpact them if necessary, and then to adjust them as nearly as possible to their correct position.
Reduction By Mechanical Traction
- When the contraction of large muscles exerts a strong displacing force, some mechanical aid may be necessary to draw the fragments out to the normal length of the bone.
- This particularly applies to fractures of the shaft of the femur and certain types of fracture or displacement of the cervical spine.
- Traction may be applied either by weights or by a screw device, and the aim may be to gain full reduction rapidly at one sitting with anesthesia or to rely upon gradual reduction by prolonged traction without anesthesia.
Operative Reduction
Open reduction may also be required for some fractures involving articular surfaces, or when the fracture is complicated by damage to a nerve or artery.
When operative reduction is resorted to, the opportunity should always be taken to fill the fragments internally to ensure that the position is maintained.
Immobilization
Indications For Immobilization
There are only three reasons for immobilizing a fracture:
3. To relieve pain.
- When immobilization is deemed necessary, there are four methods by which it may be affected:
- By a plaster of Paris cast or other external splint
- By continuous traction
- By external fixation
- By internal fixation.
- Immobilization by plaster, splint, or brace.
- For most fractures, the standard method of immobilization is by a plaster of Paris cast.
Plaster technique
The plaster bandages are applied in two forms: round-and round bandages and longitudinal strips or ‘slabs’ to reinforce a particular area.
Round-and-round bandages must be applied smoothly without tension, the material being drawn out to its full width at each turn. Slabs are prepared by unrolling a bandage to and fro upon a table: an average slab consists of about 12 thicknesses.
The slabs are placed at points of weakness or stress and are held in place by further turns of plaster bandage.
A plaster is best dried simply by exposure to the air: artificial heating is unnecessary.
Individual splints may also be made from malleable strips of aluminum, from wire, or heat-moldable plastic
This consists of a metal ‘halo’ or ring that is screwed to the skull and joined by bars to a plaster or plastic splint enclosing the chest.
Cast bracing (functional bracing): A brace has come to be understood as a supportive device that allows the continued function of the part.
Cast bracing, or functional fracture bracing (to use a better term), is a technique in which a fractured long bone is supported externally by plaster of Paris or by a mouldable plastic material in such a way that the function of the adjacent joints is preserved and use of the limb for its normal purposes can be resumed.
Functional bracing is used mainly for fractures of the shaft of the femur or tibia.
Immobilization By Sustained Traction
This is particularly so when the plane of the fracture is oblique or spiral, because the elastic pull of the muscles, then tends to draw the distal fragment proximally so that it overlaps the proximal fragment.
In such a case, the pull of the muscles must be balanced by sustained traction upon the distal fragment, either by weight or by some other mechanical device.
Immobilization By External Fixation
- Strictly, immobilization in plaster or in a splint might be regarded as external fixation.
- By convention, however, the term external fixation is used to imply anchorage of the bone fragments to an external device such as a metal bar through the medium of pins inserted into the proximal and distal fragments of a long bone fracture.
- In its simplest form, external fixation may be provided by transfixing each fragment with a Steinmann pin and incorporating the protruding ends of the pins in a plaster of Paris splint.
- This simple method is now seldom used, and fiction is now using rigid bars or a frame.
- Metal plate held by screws or locking plate (with screws fixed to the plate by threaded holes)
- Intramedullary nail, with or without cross-screw fiction for locking
- Dynamic compression screw-plate
- Condylar screw-plate
- Tension band wiring
- Transfiion screws.
Locking plate: A newer concept is the ‘locking plate’, which uses screws with heads that are threaded and when tightened lock into matching threads in the holes of the plate.
- This produces a more rigid fixation in terms of length and angle, which is particularly valuable in comminuted fractures in osteoporotic bone.
- It can also be inserted with less stripping of soft tissue that preserves bone vascularity, particularly in the metaphyseal region.
The screw component, which grips the femoral head, slides telescopically in the barrel to allow the bone fragments to be compressed together across the fracture. This compression effect is brought about by tightening a screw in the base of the barrel.
Kirschner wire fixation: These thin flexible wires with sharpened ends are available in several diameters and provide a useful alternative to transfusion screws for the fixation of small bony fragments or for fractures of the small bones in the hand and foot.
Tension band wiring: This technique of fixation is most commonly used in the patella and olecranon, but can be applied to other small metaphyseal fragments such as the medial malleolus. It uses the mechanical principle of converting the tensile stresses of the muscles acting on the bone fragment, into a compressive force at the fracture site.
- Improved results in the treatment of fractures owe much to rehabilitation, perhaps the most important of the three great principles of fracture treatment.
- Reduction is often unnecessary; immobilization is often unnecessary; rehabilitation is always essential.
- Rehabilitation should begin as soon as the fracture comes under definitive treatment.
- Its purpose is twofold: first, to preserve functions of areas possible while the fracture is uniting, and second, to restore function to normal when the fracture is united.
- This purpose is achieved not so much by any passive treatment as by encouraging patients to help themselves.
- The two essential methods of rehabilitation are active use and active exercise.
- This implies that the patient must continue to use the injured part as naturally as possible within the limitations imposed by necessary treatment.
- The degree of function that can be retained depends upon the nature of the fracture, the risk of displacement ofthe fragments, and the extent of any necessary splintage.
- Although in some injuries rest may be necessary in the early days or weeks, there should be a graduated return to activity as soon as it can be allowed without risk.
- These comprise exercises for the muscles and joints. They should be encouraged from an early stage. While a limb is immobilized
- in plaster or splint, exercises must be directed mainly to the preservation of muscle function by static contractions.
- The ability to contract a muscle without moving a joint is soon acquired under proper supervision.
- When restrictive splints are no longer required, exercises should be directed to mobilizing the joints and building up the power of the muscles.
- Finally, when the fracture is soundly united, treatment may be intensified, movements being carried out against gradually increased resistance until normal power is regained.
Hematoma and granulation tissue formation
- After fracture, a hematoma is formed due to the rupture of blood vessels
- Inflmmatory changes start at the site of fracture
- Hematoma is gradually resorbed
- The necrotic debris is removed by neutrophils and macrophages
- Collagen fibers are laid down at the site of the union of fracture
- Capillaries and collagen fier form granulation tissue which covers the fracture site, it takes about 15 days
- Bone ends are now united at the fracture site, by a weak fibrous band.
- Calcification of newly formed fibrous tissue takes place after 3 weeks
- Matrix becomes ossified and is called ‘Callous’
- Callous is distributed along the fractured site
- Callous provides a firm and rigid bridge at the fracture segments.
- The callus is now replaced by a lamellar bone. The bone undergoes remodeling and comes in normal morphology
- The haversian system develops in the bone
- Bony union takes place in about 2 to 3 months.
- TMJ ankylosis: There is immobility of the joint, and the jaw function gets affected. Hypomobility to immobility of the joint can lead to inability to open the mouth from partial to complete
- Two main factors predisposing to the ankylosis are trauma and infection, in or around the joint region.
- Early surface intervention
- Aggressive resection: A gap of at least 1 to 1.5 cm should be created.
- Ipsilateral coronoidectomy and temporalis myotomy.
- Contralateral coronoidectomy and temporalis myotomy.
- The lining of the glenoid fossa region with temporalis fascia.
- Reconstruction of the ramus with costochondral graft.
- Early mobilization and aggression physiotherapy for at least 6 months postoperatively.
- Regular long-term follow-up.
- To carry out cosmetic surgery at a later date when the growth of the patient is complete.
- Removal of the ankylosed mass of bone to mobile the jaw.
- Reconstruction of joint and maintenance of vertical height of ramus.
- Prevention of recurrence.
- Restoration of occlusion and maintain function.
- Correction of secondary facial deformity.
- Use of basement force: Forced opening of the jaw by mouth gag under general anesthesia. It is used in the case of fibrous ankylosis.
- Surgical lysis: Opening of joint by preauricular approach and destroying the union of condyle and glenoid fossa.
- This procedure is done in cases of fibrous or partial ankylosis where the anatomical features of the joint are not completely changed.
- The condylectomy procedure should be started by giving the preauricular incision.
- Now a horizontal osteotomy cut is given with the help of a bur at the level of the condylar neck.
- Section the head of the condyle to the level of the neck and separate it from the superior attachment.
- The stump of the condyle at the neck is smoothened and the wound is closed in layers.
- As unilateral condyle leads to deviation of the mandible at the operated side on mouth opening and in cases of bilateral ankylosis open bite is present due to loss of vertical rami.
- So when condylectomy is done, after recontouring an alloplastic material is used to maintain space and provide proper occlusion as well as joint movements.
- Gap arthroplasty is the procedure that involves the creation of an anatomical gap in an ankylosed segment to form an artificial joint space.
- In patients with complete bony ankylosis anatomical features of joints are very difficult to appreciate as they get covered by the bone. So in complete bony ankylosis cases, a gap in the bone is made to separate the ramus of mandible from the ankylosed mass in the glenoid fossa.
- Now two horizontal bony cuts are given in the superior aspect of the ramus and the wedge of bone between the two cuts is removed. Take care while removing the bone from the medial aspect as it is close to a maxillary artery and carotid canal.
- Remove the bone by using a large round bur till the medial bone gets thinned out completely to remove by osteotome.
- There is a recommendation of leaving a gap of about 1 to 1.5 cm laterally and medially to prevent ankylosis.
Interposition Arthroplasty
- In cases of gap, arthroplasty chances of ankylosis are present, if bony cuts come in contact.
- So to avoid this an interpositional material is inserted in between the two cut ends which avoids contact between them and decreases the chances of ankylosis.
- Various materials are used which can be autogenous or alloplastic.
- Autogenous materials used for interposition are cartilaginous graft, temporal muscle, temporal fascia, fascia, and dermis while alloplastic materials used are metallic and non-metallic.
In metallic ones, there are tantalum plates, stainless steel, titanium, and gold, and in non-metallic ones, there are Teflon, acrylic, ceramic, and elastic.
- General airway: Administer oxygen and maintain a patent airway. Maintain an immobilized cervical spine at all times.
- Clear the mouth of any foreign body or debris, and suction any blood present.
- Intub ation: Intubate, if indicated. Have the cricothyroidotomy and tracheotomy tray set up before an initial attempt at intubation?
- Consider conscious sedation intubation, if distortions of the mandible and maxilla exist because a tight seal with the mask may not be possible when bagging.
- Consider nasotracheal intubation, if massive oropharyngeal edema is present.
- Consider orotracheal intubation, if midface or upper face trauma is present.
- If unable to intubate the patient nasotracheal or endotracheally, cricothyroidotomy is the next procedure of choice
- Breathing: Assess breath sounds. Check tube placement.
- Circulation: Do not remove impaled foreign bodies that can result in worsening of damage and bleeding.
- Control hemorrhage with direct pressure.
- Obtain large-bore intravenous access bilaterally.
- Disability: Assess the patient using the Glasgow coma scale.
- Perform a brief neurologic examination.
Note any change in mental status. - Exposure: Expose patients, but keep them warm. Remove all clothing and accessories.
Recover all avulsed hard and soft tissue, and transport them in damp gauze with no ice and very little manual manipulation.
- Generalmedical therapy: Administeroxygenand, isotonicity stalled flids.
Administer packed red blood cells if the patient is bleeding excessively. Tetanus prophylaxis is indicated. - Antibiotics: For facial lacerations, use cefazolin (Ancef,Kefzol).
- For oral cavity lacerations, use clindamycin or penicillin.
- For fractures communicating with the sinus, use amoxicillin. For fractures with dural tears or CSF leaks, use vancomycin and a third-generation cephalosporin.
- Pain management: Use oral medications for minor injuries and parenteral medications if the patient cannot take oral medications (i.e., anything by mouth [NPO]).
For antiinflammatory control, use ibuprofen, naproxen, or ketorolac (Toradol). For central control, use narcotics (e.g., codeine, oxycodone, hydrocodone, meperidine, morphine).
- Of great concern is the patency of the nasofrontal duct. If this duct is blocked, surgery is indicated.
- Blockage may result in mucocele or abscess.
- Non-displaced anterior sinus wall fractures are treated by observation.
- Displaced anterior sinus wall fractures with severe comminution and mucosal injury require neurosurgery, oral and maxillofacial surgery, otolaryngology, or plastic surgery for bone grafting and frontal sinus obliteration.
- Treatment of posterior sinus wall fractures is controversial and variable.
- Posterior sinus wall fractures are examined for displacement, dural tears, and cerebrospinal fluid leakage.
- Non-displaced fractures with a cerebrospinal fluid leak may be observed for 5–7 days while undergoing treatment with intravenous antibiotics. Frontal sinus obliteration is indicated if a cerebrospinal fluid leak persists.
- Surgical treatment of displaced fractures with no cerebrospinal fluid leak is based on the severity of comminution.
- Mild comminution requires osteoblastic flu and sinus obliteration.
- Comminution of greater than 30% of the posterior sinus wall requires the neurosurgeon to remove the posterior table allowing the brain to expand into the frontal sinus, this is known as cranialization.
- Displaced sinus wall fractures with a cerebrospinal fluid leak and minimal-to-mild comminution require sinus obliteration.
- Moderate-to-severe comminution requires sinus cranialization.
- Blow-out fractures of the orbital floor require consultation with an ophthalmologist and maxillofacial trauma specialist (e.g., oral and maxillofacial surgeon, otolaryngologist, or plastic surgeon).
- Several approaches are available including subsidiary, subtarsal, transconjunctival, and transconjunctival with lateral canthotomy. The subsidiary approach has the most complications (e.g., ectropion), and the transconjunctival approach has the least complications.
- However, when major surgical exposure is necessary, a transconjunctival approach with or without a lateral canthotomy incision is recommended.
- Orbital flor repair via sub-tarsal approach.
- Nasal fractures should be managed between days 2–10.
- This allows time for the resolution of the edema and therefore assists in obtaining the best reduction possible.
- After 10 days, achieving good closed reduction results may be difficult and it may be necessary to wait for as long as 6 months to obtain satisfactory good results via an open reduction technique.
- Fractures with suspected or detected dural tears require consultation with a neurosurgeon, and the patients should be admitted for observation and intravenous antibiotics.
- An ophthalmologist should be consulted for repair of the lacrimal apparatus if disrupted.
- An oral and maxillofacial surgeon, plastic surgeon, or otolaryngologist should be consulted for the repair of nasal bones, medial canthus, and the nasofrontal duct.
- Patients with isolated minimally displaced fractures to the zygomatic arch usually do not require treatment, unless it caused a facial asymmetry.
- Marked displacement and/or impingement ofthe coronoid process of the mandible, preventing the patient from opening their mouth, requires admission and an open reduction via transoral (Keen) or temporal (Gillies) approach.
- In cases of a severe comminuted fracture, an open reduction with internal fixation (ORIF) may be required.
- When the impact is sufficient to sustain a fracture of the ZMC consultation with an ophthalmologist is warranted to rule out ocular injury. Like the zygomatic arch fracture, surgical treatment of a ZMC fracture is indicated when a cosmetic deformity or functional loss is noted.
- Waiting 4–5 days for the edema to be reduced is helpful to properly assess the situation.
- The standard of care is open reduction and internal fixation with mini plates and screws. The orbital floor is frequently explored and repaired, if necessary.
- When the impact is severe enough to cause mobility of the maxilla or to a part of it, the patient should be placed in intermaxillary fixation and open reduction with internal fixation should be performed at the piriform rim and zygomaticomaxillary buttress.
- Patients with a maxillary fracture should be placed on sinus precautions, and if they have subcutaneous emphysema, they should be placed on antibiotics because some of the bacterial flares could have been forced by the air into the subcutaneous planes.
- Management is provided by an oral and maxillofacial surgeon, otolaryngologist or plastic surgeon.
- Temporary stabilization in the emergency department can be addressed with the application of a Barton bandage.
- Bring the teeth into occlusion and wrap the bandage around the crown of the head and jaw. This stabilizes the jaw and greatly reduces pain and hemorrhage.
- A symphysis or body fracture can be reduced temporarily with a bridal wire (a 24-gauge wire wrapped around 2 teeth on either side of the fracture). This greatly reduces hemorrhage, pain and infection.
- Nondisplaced mandibular fractures may be treated by closed reduction and intermaxillary fixation for 5–6 weeks.
- However many patients do not want to be closed down for that length of time and prefer open reduction.
- Initially, the fracture is stabilized with intermaxillary fixation followed by open reduction and rigid fixation using
- titanium mini plates, mandibular plates, or reconstruction plates, depending on where the fracture is located.
- Nondisplaced fractures of the condyle require intermaxillary fixation for 10 days, followed by physiotherapy to help restore improved function.
- Ankylosis of the joint is extremely rare and is believed to be caused by an untreated intracapsular injury or fracture.
- At the time of surgery, tracheostomy or submandibular intubation is required.
- A submandibular intubation, which avoids a tracheostomy, is performed by first intubating orally, and then surgically bringing the tube out through the submandibular space.
- Nasoendotracheal intubation is contraindicated.
- Facial bones are repositioned beginning at the cranium.
After the occlusion is established by intermaxillary fixation, the remaining facial bones are repaired with open reduction and internal fixation.
- Fracture of the lower third which comprises of mandible
- Fracture of the middle third which comprises of maxilla, zygoma, and nose
- Fracture of the upper third of the face involving part of the orbit and frontal bones.
- Lacerations, contusions, cut wounds, etc.
- Eyelid injuries with black eyes
- Facial nerve injury: Primary repair is required
- Parotid duct injury: Primary Anastomosis of the injured duct is done, with fie polyethylene cannula kept as a stent inside the duct which is removed in 14 days.
- Lacrimal apparatus injuries: Here the duct is sutured with fine nylon thread in canaliculus which is kept for three months.
- Fracture nose: Nasal bones are the most commonly injured bones in the face.
- The patient presents with pain and swelling in the nose with deviation and displacement.
- Here reduction of the fractured nasal bones and nasal septum under general anesthesia is done.
- Later position is maintained by nasal packs from inside (which is removed in 7 days) and by a nasal plaster from outside (which will be kept for 14 days).
- The procedure is done using Walsham and Asch forceps.
- Injuries to the maxilla
- Zygomatic bone injuries.
- Mandibular bone fracture and mandibular dislocation.
- Orbital bone fracture: Presents with diplopia, enophthalmos, and sensory loss in the area of the infraorbital nerve.
- Infraorbital ecchymosis of the orbit is called the Panda sign.
- Localized swelling due to hematoma
- Facial edema
- Bleeding with open wounds
- Asymmetry which is clinically confirmed by observing supraorbital ridges, nasal bridge
- Localized tenderness
- Step deformity
- Trismus
- Diplopia
- Features of associated injuries such as intracranial, abdominal or thoracic injuries.
- X-ray face
- CT scan of head and jaw
- As the initial assessment, evaluation, and management of life-threatening injury get completed compound fracture should be treated in the following manner, i.e.
- Hemostasis should be achieved.
- For Type I and Type II compound fractures cephazolin or clindamycin are the choice of drugs while for Type III compound fractures, aminoglycoside is given.
- Tetanus vaccination should be given.
- Irrigation, as well as debridement of the wound, should be carried out immediately.
- In cases with Type II and Type III compound fractures serial irrigation and debridement are recommended for every 24 to 48 hours till a clean surgical wound is confirmed. Close the wound when it gets clean fully.
- Management of open fractures depends on their type and site. Later on wound is stabilized temporarily or definitively.
- If coverage of soft tissue after injury is not proper soft tissue transfer or free flAp is given to the patient when fracture is treated.
- Clinical diagnosis: The patient complains of difficulty in swallowing. Saliva is seen drooling over the chin. Severe pain is present in the area over the temporal fossa. In the place where the condylar head is normally placed, at that area depression is seen. There is also the presence of an anterior open bite along with gagging of molar teeth.
- Radiographical diagnosis: Due to dislocation of the condyle articular fossa space appears to be empty.
- Acute dislocation: It is done within 72 hours. Manual reduction can be done.
- It can be done with or without the use of anesthesia.
- The patient should be sitting upright on the chair.
- Clinicians should wear gloves.
- The thumbs of the clinician are positioned over lower molar teeth bilaterally.
- Index figures are placed under the inferior border of the mandible. The posterior aspect of the mandible is depressed inferiorly to depress the condyle.
- While the chin is elevated anteriorly and the entire mandible is pushed backward with the palm.
- The mandible is moved downwards, backward, and upward, manipulating the condyle back in position.
- Chronic dislocation: Manual reduction is done under general anesthesia.
- Alteration of ligaments:
- By injecting the sclerosing agent in the capsular space of TMJ.
- Strengthening ligaments by surgically exposing temporal fascia and suturing the flap of fascia on the capsular ligament.
- Alteration of musculature:
- By closed condylectomy: Gigli saw is used to intraorally bisect the condylar neck.
- Ligation of the coronoid process to zygomatic arch anterior to articular tubercle
- Alteration of bony structure:
- By colectomy
- Laminectomy, i.e. reduction of height of eminences.
- Direct spread of infection from dental pulp into the mandible.
- Spread of infection in the mandible from presenting suppurative odontogenic infections.
- Spread of infection following removable of the tooth without proper asepsis and antibiotic coverage.
- Compound fracture of the mandible with exposure of bone outside the mucosa.
- Postradiation secondary infection.
- Infection to the pre-existing bony lesions, e.g. Paget’s disease of bone and fibrous dysplasia.
- Conservative treatment.
- Surgical treatment.
- The goal of management is:
- Attnuate and eradicate the proliferating pathological organisms.
- Promote healing.
- Re-establish vascular permeability.
- The goal of management is:
- Early diagnosis.
- Bacterial culture and sensitivity test.
- Adequate and prompt antibiotic therapy.
- Adequate pain control.
- Proper surgical intervention.
- Reconstruction (if indicated).
- Complete bed rest.
- Supportive therapy: It includes nutritional support in the form of a high protein and high caloric diet and adequate multivitamins.
- Dehydration control: Hydration orally or through IV fluid.
- Blood transfusion: When RBC and Hb are low.
- Control of pain: Analgesic and sedation.
- Intravenous antimicrobial agents: Penicillin.
- Done as soon as possible.
- It relieves pain and pressure caused by pus accumulation.
- Extraction of loose or offending teeth.
- Debridement: Followed by incision and drainage thorough debridement of the affected area should be carried out.
- The area may be irrigated with hydrogen peroxide and saline thrice a day.
- Any foreign body, necrotic tissue, or small sequestrum should be removed.
- Drainage for the body and angle of the mandible area is established through an extraoral submandibular skin incision.
- Intraoral drainage can be established for the body of the mandible.
- Sequestrum formed should be removed, if it can be gently picked up (sequestrectomy).
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- Acute Osteomyelitis
- Acute suppurative osteomyelitis
- Acute subperiosteal osteomyelitis
- Acute periostitis.
- Chronic Osteomyelitis
- Nonspecific type:
- Chronic intramedullary osteomyelitis
- Chronic focal sclerosing osteomyelitis
- Chronic diffuse sclerosing osteomyelitis
- Chronic osteomyelitis with proliferative periostitis
- Chronic subperiosteal osteomyelitis
- Chronic periostitis.
- Specific type:
- Tuberculous osteomyelitis
- Syphilitic osteomyelitis
- Actinomycotic osteomyelitis.
- Nonspecific type:
- Radiationinduced osteomyelitis.
- Idiopathic osteomyelitis.
- Pain and tenderness is minimal.
- Non-healing bony and overlying soft tissue wounds with indurations of soft tissues.
- Thickened or wooden character of bone.
- History of chronic discharge in oral cavity or on face through the sinus present.
- Pathological fracture may occur.
- Teeth in area tend to become loose and sensitive to palpation and percussion.
- Lymphadenopathy is present.
- Conservative treatment.
- Surgical treatment.
- The goal of management is
- Attnuate and eradicate proliferating pathology-
- cal organism.
- Promote healing.
- Re-establish vascular permeability.
- The goal of management is
- Early diagnosis.
- Bacterial culture and sensitivity test.
- Adequate and prompt antibiotic therapy.
- Adequate pain control.
- Proper surgical intervention.
- Reconstruction (if indicated).
- Complete bed rest.
- Supportive therapy: It includes nutritional support in form of a high protein and high caloric diet and adequate multivitamins.
- Dehydration control: Hydration orally or through IV fluid.
- Blood transfusion: When RBC and Hb is low.
- Control of pain: Analgesic and sedation.
- Intravenous antimicrobial agents: Penicillin.
- Done as soon as possible.
- It relieves pain and pressure caused by pus accumulation.
- Extraction of loose or offnding teeth.
- Debridement: Followed by incision and drainage thorough debridment of affcted area should be carried out.
- The area may be irrigated with hydrogen peroxide and saline thrice a day.
- Any foreign body, necrotic tissue or small sequestrum should be removed.
- Drainage for the body and angle of the mandible area is established through extra oral sub mandibular skin incision.
- Intraoral drainage can be established for the body of mandible.
- Sequestrum formed should be removed, if it can be gently picked up (sequestrectomy).
- Removal of sequestrum.
- It may be carried out under proper cover of antibiotics.
- Small sequestra are removed under local anesthesia.
- General anesthesia may be given for the removal of bigger sequestrum.
- Sequestra from lower border of mandible are best removed by extraoral approach using Risdon’s incision.
- Fromramus, itmaybe removed by retromandibular incision.
- From condyle by preauricular incision.
- Coronoid process is best approached by or intra oral incision given along the anterior border of ramus of the mandible.
- After removal of the sequestrum the residual granulation tissue is curettd till white shining bone appears.
- Bleeding is controlled by pressure pack.
- When complete infection has been eradicated the wound can be closed by primary closure.
- When the elimination of the infection is doubtful, a glove drain or a rubber drain is kept in place and is changed every 24 hours till no discharge from the bone, is seen.
- Removal of bony cavity.
- It consists of elimination for bony cavity in the jaw bone to avoid collection of blood and formation of large hematoma which is liable to get infected.
- It is simple procedure for eliminating the dead space inbone.
- Saucerization is carried out by existing the wall of the bony cavity by means of Rongeur bone-cuttng forceps or burs.
- The bone is smoothen by flie.
- The wound can be partially or completely closed depending upon the amount of suppuration.
- Direct wiring:
- Direct interdental wiring
- Eyelet
- Continuous or multiple-loop wiring
- Risdon’s wiring.
- Arch bars:
- Erich
- German silver
- Jelenko.
- Intermaxillary fiation:
- Dental wiring:
- Direct Interdental
- Eyelet
- Continuous or multiple loop wiring
- Risdon’s wiring.
- Arch bars:
- Erich
- German silver
- Jelenko.
- Cap splints.
- Dental wiring:
- Intermaxillary fiation with osteosynthesis:
- Transosseous wiring
- Circumferential wiring
- External pin fiation
- Bone clamps.
- Osteosynthesis without intermaxillary fiation:
- Non-compression small plates
- Compression plates
- Mini plates.
- Use when all teeth are present.
- A 26 gauge, 25 cm long wire is passed around the neck of the 2nd molar on each side so that both ends of wire extend to buccal side.
- Than the ends of both wires twisted together for their entire length.
- So that the strong base wires is formed on either side, coming towards midline from each second molar.
- The excess wire is cut and the ends are checked in inter dental space.
- The base wire is secured to individual tooth by using additional inter dental wires.
- The one of small wire is passed from the distal surface of the tooth below the base wire and brought out towards the lingual side and then brought out on the buccal surface from mesial interdental space above the base wire.
- Both ends are again grasped together and twisted, cut and fiished in interdental space.
- Each tooth is engaged in the same manner to the base wire,so that the base wire is fully secured to the dental arch.
- Two types of horizontal wiring after strong fiation and prevent supraeruption.
- There are many types of arch bars available.
- Rigid types are made by half round stainless steel wire of 18 and 21 gauge.
- The read-made arch bars are available (Erich arch bar)
- These are consider bettr as these are soft, easy to adapt and have hooks.
- The arch bars are indicated when there are not enough teeth in the arch for conventional Risdon’s wiring or when all teeth in arch cannot be secured due to poor periodontal condition of teeth.
- The arch bar should be perfectly adapted to the teeth in the arch because if the bar is not fitd, it can cause orthodontic movement.
- The arch is adapted by starting from distal most point in the arch.
- A sharp bend is given at the edge of wire to be pushed into the interdental space between 2nd and 3rd molar to avoid slippage of arch bar.
- It is adapted progressing to midline and fiishing on other end.
- Arch bar should not cross the fracture line.
- The bar should be cut and adapted to each fragment separating.
- The arch bar is secured in place by using ligature wire passed around each individual tooth.
- One end of the wire coming below the arch bar and above it in the buccal side and then fiished.
- Care is taken that hooks on the arch bar are directed upward in the maxilla and downward in mandible
- There are two method of wiring: The upper border wiring and lower border wiring, in case of angle and body of the mandible.
- The upper border wiring is done intraorally just below the alveolus and lower border wiring is done by extraoral approach.
- The edges ofbony fragments are cleaned and reduced with the help of “Bone-holding” device.
- Holes are drilled in the bone using an electric or “hand drill”.
- Drilling is done under constant jet of normal saline solution.
- The holes should be drilled at a distance of atleast 5 mm from the fractured site.
- A no 26-gauge wire is passed through the holes across the fracture line and tightened by trusting the two ends.
- In multiple mandibular fractures, accurate reduction and establishment of normal occlusion is tuf, so it is advisable to secure the normal occlusion through interdental wiring before the miniplate osteosynthesis is performed.
- Following reduction, the osteosynthesis lines should be established.
- The adaptation of the bone plate is done by bending pliers.
- Adapted bone plate should lie passively over the contour of external cortex, and it is confirmed that there should not be any gap between the plate and the bone.
- The miniplate is fied in its specifi position with the screws.
- In fractures of the angle of the mandible, plate is located on the posterior fragment, medial to the external oblique line, this is done so that it can be bent over the surface and the posterior screws are placed in sagittl direction.
- In cases with simultaneous fractures of the alveolar process or if impacted third molar teeth are present, the plate may be fied to the outer surface of the mandible which correspond to the position in the course of line of tension.
- When fracture is present between the canine and premolars, mental nerve may be damaged by applying the plate. In such cases, it is recommended to place concave section of plate between screw holes precisely at the exit point of the nerve.
- In some of the very exceptional cases, transposition of nerve to lower level may be indicated.
To reduce the effect of torsional forces in symphysis region between mental foramina, it is mandatory to use two parallel plates. - In the cases of comminuted fractures or in cases where there are detached triangular pieces of bone, longer plates with six or more screws should be used.
- If the bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone, the fracture is called as compound fracture.
- For example, when a pedestrian is struck by the bumper of a moving car, the broken shinbone may protrude through a tear in the skin and other soft tissues.
- Since compound fractures ofteninvolve more damage to the surrounding muscles, tendons, and ligaments,they have a higher risk for complications and take a longer time to heal.
- This type of fracture is particularly serious because once the skin is broken, infection in both the wound and the bone can occur.
- Type I: Wound is smaller than 1 cm, clean and generally caused by fractured fragment which pierces the skin. This is a low energy injury.
- Type II: Wound is longer than 1 cm, not contaminated and is without major soft tissue damage or defect. It is also a low energy injury.
- Type III: Wound is longer than 1 cm with signifiant soft tissue disruption. Mechanism involves high energy trauma,resulting in severe unstable fracture with varying degrees of fragmentation.
- Type IIIA: Wound has suffient soft tissue to cover the bone without need for local or distant flp coverage.
- Type IIIB: Disruption of soft tissue is extensive such as local or distant flp coverage is necessary to cover the bone. Wound may be contaminated, serial irrigation and debridement procedures are necessary to ensure clean surgical wound.
- Type III C: Any open fracture associated with an arterial injury requires repair is considered as Type IIIC.
- Compound fractures are caused by high-energy trauma, most commonly from a direct blow, such as from a fall or motor vehicle collision.
- These fractures can also occur indirectly, such as a highenergy twisting type of injury.
- X-rays will show how complex the fracture is.
- Routine blood and urine tests provide information about the general health.
- Antibiotics are started as soon as possible in the emergency room.
Severity of injury determines which antibiotics are given. Tetanus shot should be given.
Cefazolin /clindamy cin is given the Type I and Type II open fractures while for type III fractures aminoglycoside is given. - Injury will be covered with a sterile dressing.
Doctor will gently put the bones back into alignment to prevent the fragments from causing further damage to soft tissues. - Then splint should be applied to injured limb to protect it and keep it from moving until patient is taken to surgery.
- Débridement: During this procedure, surgeon will remove all dirt and foreign bodes, as well as any contaminated and unhealthy skin, muscle, and other soft tissues.
The bone is also cleaned of all dirt and other foreign material. Any unattched pieces of bone are removed.
Severely contaminated bone fragments are also discarded. This bone loss can be corrected later with additional surgeries. - Irrigation. After débridement, the wound is cleansed and irrigated with several liters of saline.
- It is important to stabilize the broken bones as soon as possible to prevent further soft tissue damage.
The broken bones in an open fracture are typically held in place using external or internal fixation methods.
These methods require surgery. - For type II and type III compound fractures, serial irrigation and debridement is done till clean surgical wound is achieved.
- The fragments may also be held together by inserting rods down through the marrow space in the center of the bone.
- These methods of treatment can reposition the fracture fragments very exactly.
- Because open fractures may include tissue damage and be accompanied by additional injuries, it may take time before internal fiation surgery can be safely performed.
- In external fiation, pins or screws are placed into the broken bone above and below the fracture site.
- Then the orthopedic surgeon repositions the bone fragments.
- The pins or screws are connected to a metal bar or bars outside the skin.
- As fiation gets completed the skin should be sutured.
- In complex wounds, flaps should be place to cover the injury.
- Infection is the most common complication of open fractures. Infection can occur early, during the healing phase of the fracture, or even later.
- In general, the greater the extent of soft tissue damage, the greater the risk for infection.
- If an infection becomes chronic (osteomyelitis), it may lead to further surgeries and amputation.
- Compound fractures may have difficulty healing. If your fracture is failing to heal, further surgery may be required.
- Surgery to promote healing usually includes placing a bone graft over the fracture, as well as new internal fixation components.
- Acute compartment syndrome may develop.
- This is a painful condition that occurs when pressure within the muscles builds to dangerous levels.
- Unless the pressure is relieved quickly, permanent disability and tissue death may result.
- There is presence of deep intense pain.
- The patient complains of intermittent fever.
- Signs of acute infection are present, i.e. bodyache, malaise,leucocytosis, raised ESR, etc.
- Presence of paresthesia or anesthesia oflower lip as inferior alveolar nerve is involved.
- Acute infection is present in the tooth and pus discharge is seen from gingival crevice.
- Presence of mobility of involved teeth.
- If the infection is left untreated, an abscess may develop in the bone and surrounding tissue.
In time, this may burst on to the skin and leave a tract i.e. sinus between the infected bone and surface of the skin. - Blood infection, i.e. septicemia develop which cause serious illness.
- If the infection follows a fracture, then there is a chance that the fracture will not heal, i.e. there is non-union of fracture.
- Compression of other structures occur next to the infection.
- Some bone infections are caused by methicillin-resistant S. aureus (MRSA) which is difficult to clear with antibiotics.
- Persistent infection of the bone, i.e. chronic osteomyelitis sometimes develops and can be difficult to clear.
- Based on plane of fracture surface:
- Linear fractures: Fracture which run parallel to long axis of bone.
- Transverse fracture: Fracture in right angle with axis of bone
- Oblique fracture: Fracture with oblique fracture line
- Spiral fracture: Fracture with spiral fracture line
- Comminuted fracture: Fracture with splintered or crushed bone with more than two fragments.
- Segmental fracture: Fracture, where a part of bone is completely separated from, are not bone with same diameter.
- Based on etiology of fracture:
- Traumatic fractures
- Pathological fractures
- Stress fractures
- Based on condition of soft tissue:
- Close or simple fracture: This fracture lacks communication between site of fracture and exterior of body
- Open or compound fracture: In this, fracture a wound is present through the adjacent or overlying soft tissue communicates outside the body.
- Special fractures:
- Depressed fracture: It is common in skull bone
- Fracture-dislocation: Anterior dislocation of shoulder along with fracture neck of humerus.
- Fracture involving a joint
- Complex fracture: These fractures involve major nerves and vessels.
- Swelling or bruising over a bone.
- Deformity of an arm or leg.
- Pain in the injured area that gets worse when the area is moved or pressure is applied.
- Loss of function in the injured area.
- Bone appears protruding from the skin.
- Bleeding is present at the fracture site.
- Presence of contamination of fracture site by mud, dirt,etc.
- Victim heard a bone break or snap or heard a grating sensation.
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