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Upload it later and you guys can have a look. Um So my name is Jan V. Um I'm an Maxx specialty doctor. Um My background is I did dentistry first, then did medicines. I've been working in for many years in Max fax and now in medicine. Um So the purpose of this presentation is to kind of give you an overview of facial trauma and what you would see as medics. I think often things come up quite frequently in GP practices, A&E departments and even on medical and surgical wards. And I think it's good to have a basic understanding of when to refer, how to refer and what kind of basic knowledge that you need. So, in this presentation, we're gonna go through how to take a thorough history from any facial trauma or trauma patient, how to do a comprehensive examination. Um the investigations that are important to request some common facial fractures and kind of what the basic management is. No one's expecting you to come out of this as surgeons. But just so you have an idea of what they do facial lacerations, again, commonly seen in A&E departments and GPS and then finally, a little bit about dental trauma because I think it's becoming more important um as NHS dentistry changes. Perfect. So as I was saying, um facial trauma commonly presents to both emergency departments and in primary care, obviously, more advanced facial trauma will be redirected to major trauma centers. Um However, more basic trauma can come to a any A&E department due to the proximity of vital structures in the head and neck area. It's essential that you assess these injuries appropriately and escalate when needing when needed. Um It's important to remember that uh specialty services such as Maxx neurosurgery ent plastics, people who commonly deal with the head and neck are not on the site or even present at a lot of hospitals, especially smaller ones and you often have to refer to a tertiary center. So knowing when to do that, when that's appropriate or when it can just be dealt with by the emergency department or by a GP is really helpful and it will stand you in good stead to be able to triage these patients accordingly. So history is kind of obviously you're gonna take your basic medical history first complaints, medical history, social history, um drug history. But then in specific with facial trauma, it's really important that you really delve into what their main presenting complaints and symptoms are. And what I mean by that is, have they noticed their teeth are biting differently? They can't see properly. Um What exactly it is not just I have a cut on my face. If there's anything else more important, then it's good to know that I think a good way of going about the history of any trauma patient is to obviously do these questions. But also think about when who, what, where, why and how and that will make sure that you cover everything, especially with trauma patients where there's a history of assault traffic accidents, things like that. It's important to know the date location and time of the incident, many of our patients present very late. Um And that's obviously important in terms of infection risk and things like that mechanism of injury is really important again. So for example, if someone's been in a road traffic accident, really thorough history. So whether the driver, the passenger, what kind of vehicle was it, were they wearing a seatbelt or were they wearing a helmet? If it was a motorcycle? Similarly, if it was an assault, what exactly happened? What was the mechanism of the assault? Was it single punch, single kick, multiple punches? Which side of the face did they hit? Um How many blows did they have? And the exact location of where things happened with sports? Again, a common thing we see. Uh again, how did it happen? What was the exact injury? Is it a contact sport? A non contact sport is the other person injured? Um How exactly did it happen? And often it's useful to other people will have seen all these incidents happen. And finally, I'm sure you guys are all um as medics were used to taking a falls history. So were they walking, running? What happened before the fall during the fall after the fall? Was it from a height? Um, often when people come in with kind of obvious facial injuries, it is unfortunately missed that they have any other body injuries. So just check, have they hurt their limbs, their abdomen, their chest, anything else, even slightly cos sometimes they, these things can be missed if they've got a massive bleeding wound on their face. Is there any police involvement? Unfortunately, a lot of these patients have a lot of police involved and it's important to make a note of that for kind of future issues. Um really important to find out if there are any signs of an intracranial injury. So any loss of consciousness, vomiting, nausea, headaches, normally, um triage in A&E is very good at that. But if patients present late, sometimes it can be missed. And again, in looking at alcohol and drug involvement, has the patient got capacity currently, what else was happening? And during that time, is there anything else we need to be aware of? So after a thorough history, we do a thorough examination. So everyone's kind of got their own system. I think the important thing is to with anything in medicine, use a systematic approach, um find something that works well for you and then just keep doing that. Obviously, at the beginning, it's really easy to miss things. So I, the way I've done this is systematically to work down the face, which I think works well. So you just make sure you're not missing any important structures or anything like that. Um And it's really important to do this for specialty referral. So for example, if you get to the cranium and there's an obvious skull fracture, of course, you need to call neurosurgery immediately. If there's things that need to go to plastics max FX ent, it's really important that the examination kind of guides your referral appropriately. Um And that will just make you a a more confident doctor and it will also give the specialty more confidence in your referral as well. So, what we'll do next is I'm gonna go through each of these in a little bit more detail. Um Obviously, if there are any questions, any comments, anything like that, just pop it in the chat and I'll try to answer it as we go along. So general inspection, I would like to say, first of all, start with, obviously, the patient in front of you. Look at them side, front on, are there any obvious wounds, bleeding, burns, uh any swelling or bruising, any signs of facial asymmetry? Uh You just have a good eye and have a look obviously, then have a look at the back of the head the neck everywhere. You can, um, just remember that often facial wounds do bleed a lot, a lot, a lot because it's such a highly vascular area. So just be if you see obviously a bleeding wound, put some pressure on it and try to stop it. The good thing is most of them do stop. Unless you've hit an artery, they do stop very quickly. But it can be very scary for both the doctor, the patient, the relatives, everyone who's with them. So first of all, just look at the patient. Second of all, I would recommend looking at the cranium and the ears. So if you look from the top, um obviously, this would be easier in real life. It's hard to do it through a online system. So I've tried to use these skulls, but if you look at the top palpate for any deformities, any depressions, um and then assess the ears for any soft tissue injuries. Are there any lacerations? The uh pinna in particular, is there a hematoma? And then I would do a brief examination of the external auditory canal. Obviously, if you see something that doesn't look right, so say there's something coming out, there's blood, there's possibly CSF there's something or any foreign bodies, then try to find an otoscope and have a look. But for most patients, you won't need to. But if you do obviously have a proper look inside next as we work down the face, then So we'll look at the frontal bone. So with this really important to palpate for any deformities, so just have a feel. So make sure both sides are symmetrical. And then at this point, I would also examine the trigeminal nerve um and the uh V one. So the top branch um just to check that there's no changes in sensation to do, this is just like a normal neuro exam. Just get them to close their eyes. Can you feel light touch? And I think you only really need to do light touch unless you see something that doesn't seem right often. Um We'll come on to this a bit more later but the face, a lot of the um sensation, nerves are incredibly superficial. So if you have a bruise or a hematoma or a little fracture, you can get numbness of these, they're not worrying, but they do indicate something going on underneath. And majority of patients, the sensation does come back in a few days once the swelling resolves or the fracture is fixed or mainly it's just swelling coming down because the nerve isn't compressed. And it's really common in both all areas to be honest of the trigeminal nerve. So it's not a worrying sign, but it shows that maybe they need some more imaging or is there a fracture underneath? Are you worried about something? This shows a patient with obvious frontal bone deformity. The all frontal bone fractures need an urgent ct scan, but we'll come on to why that is later on. Ok. Next we'll look at the orbit and this is normally the bit that medics are very good at because obviously we examine eyes quite frequently, but there's some things to just keep in mind when doing it for trauma. So the most, most of the time I get a call from the A&E rsho saying we haven't been able to look at the eye because it's swollen. When people have a black bruised eye, it's really difficult. I'm sure you've all seen patients where the eye is so swollen, they can't even open it. It's really important that the first thing we do is get this eye open because this could be kind of vision saving and the way I like to do it is most of that swelling is normally emphysema from either a fracture or just air getting in through a wound or something. So you can get two cotton wool rolls and just pry the eye open, it will be painful for the patient. But just tell them I need to do this really quickly just to check and even if you don't have help and you can't check everything, just check that they can see out of that eye. That is the most important thing. Have they lost vision? Is their pupil? OK. Is there any subconjunctival hemorrhage? So just make sure you look at that really carefully. It's really important to do it because sometimes even if you refer to a specialty ophthalmology or max fax, it's gonna take some time for them to come. And if the patient's vision is going, then unfortunately, you'll be the one to blame if you don't open the eye. So it's really important, just get two cotton wool rolls and just slowly pry the eye open. It's good to have a helper at this point because one of you can pry the eye open and one of you can check things. Um after you've done that, if you examine the eye for any subconjunctival hemorrhage, so any redness in the white bit of the eye, um often this is nothing as we know this can be caused by many things, but it can be an indication of an orbital fracture. Then I would palpate the periorbital tissues to look for emphysema tenderness and especially at the bottom here. Uh just look for any step deformity. So is there any way you can see that there's an obvious break? Um Next, look at the pupil reaction to light. So you wanna check um that the pupils are equal and reactive to light and obviously check for contralateral as well. Then check for eye movements. And the only difference to how you normally do this is I would also say to the patient, put one finger up, then move it side to side and just ask them, is there any point that one finger becomes two fingers? Um this is important because we want to assess the muscles and if there's any entrapment as well. Um And again, it's not worrying, but it can indicate that there's a fracture underneath. So just get them to move um, their eye and just say, is the one finger still or two fingers and finally check visual acuity. Ideally, we should use a Snellen chart, obviously, when people have really swollen eyes, it's really difficult. Um So then I would just try to do counting fingers or whatever you can in the moment just to check that they have some sort of visual acuity um if they don't and any of this is wrong, they need to be urgently seen by ophthalmology. So um we'll come on to why later, but it's really important that you flag this quite urgently compared to all the other things we've gone through. Obviously, someone's vision is really important and it's something that can go very very quickly to any concerns. Just let someone know, OK, next one, move down the face to the nose. So as you can see this patient obviously has some deviation, but sometimes it's really hard to tell because most patients, if they have nasal fractures are really swollen. So do they have any deviation, any flattening of the nose? Again, palpate for any bony tenderness, inspect for any rhinorrhea or epistaxis um and assess the patency of each nostril. So just ask the patient to breathe through each nostril can they breathe through it. And then finally, for this thing, it's really important to assess for septal hematoma. So, the way to do that, and I think I have a picture later showing what it looks like is to get the patient to tip their head all the way back and look from the bottom up and it's just check that they don't have a septal hematoma. And if they do, they urgently need to be referred to ent, OK, then we'll move down to the Zygoma or the cheekbone. Obviously, cheekbones really commonly broken, especially in sports injuries and punches, um really important to check for bony tenderness. Um and also front on. Sometimes the flattening like in this patient is really obvious. You can see the cheekbone has definitely gone. Sometimes it's not very clear. So the best thing to do is tip the patient again, look from the top down and see are the cheek bones symmetrical. Does one look flatter than the other? Just basically whenever you're doing this examination, you're just looking for symmetry, something's off with the symmetry. Unless the patient's known to have it, there might be something going on. Finally, for this stage, also inspect for Trismus to just get the patient to open their mouth and move their jaw side to side because sometimes the mandible and the Zygoma are in very close contact. Sorry, I am rushing through this because I don't want you to do that much of an examination, but just stop me if there are any questions in specific. OK. So next, we'll go on to the maxilla. So again, just moving down the face. So there are two steps to the maxilla. When you're examining it, you need to look outside the mouth and inside the mouth. Um And I think um as medics, we're often quite bad at looking inside, we're very good at looking outside. So first of all, just start simply by palpating for any bony tenderness. Is there any deformity? Any facial asymmetry? This patient again, it's obvious there's some facial asymmetry. Um after they've you, after you've looked from the outside, then you want the patient. Oh sorry. One more thing on the outside is check again for the trigeminal nerve in this area. So you wanna check infraorbitally and all around the lips, then get the patient to open their mouth. You wanna check for mobility of the maxilla by just holding onto the palate and trying to move it forward or backwards. You only wanna do this once really because if they have an unstable maxilla fracture, you can hit a more blood vessels and cause bleeding, but it does need to be checked once. If someone's got unstable maxilla fracture, obviously, they're at risk with their airway. So if it's very unstable, you'll need to call for some help. Then when you're looking inside, just look for any defects or tenderness of the hard palate. Is there any bleeding, any cuts in the hard palate, are there any missing or fractured teeth that can indicate something and then finally assess for malocclusion. So, are the teeth meeting correctly? But we'll come onto this in more detail when we look at the bottom teeth, cos obviously, you can do both together. So next, we'll go on to the mandible. So the mandible is probably one of the most commonly broken bones in the face. Uh really, really common after falls assaults, really, really common. So I think the best thing to do again is split it into extra oral. So outside the mouth and intra oral, outside the mouth, make sure to palpate both TM. Js just check, there's no pain, assess for numbness. This is really important in this the mandibular branch of the trigeminal nerve. Do they have any tenderness? Uh any numbness or funny feeling in their lips, their chin, their teeth or even in the angle of the jaw, then I would say uh palpate for any step deformities or bony tenderness. Sometimes if you can feel here that there's a step, obviously, there's a fracture there. Um then you want to assess their mouth opening. So ask the patient to open as wide as they can and then measure that in millimeters from the top incisor to the bottom incisor. Normal mouth opening should be about 35 to 40 millimeters. Um So just record it. And so that people know, obviously, people with mandible fractures can't open their mouth very wide. Um, but sometimes it's only because of pain. So it's difficult to determine. Are they not opening their mouth? Cos it's painful or are they not opening their mouth because there's an actual obstruction and you can just try pry it open slowly and if you can physically pry it open, but it's causing them pain. You know, it's not because of a broken bone. It's just because of the swelling, it's so painful. Um And then obviously look for facial swelling, deformity, anything obvious that you can see from the outside, then we move on to the inside. So this person obviously has an obvious facial deformity, obvious mandible fracture, get the patient to open their mouth. And first of all, look under the tongue for sublingual hematoma. If patients have this, it's very, very likely that they have a mandible fracture. And it's also something to keep in mind that this can swell quite significantly, quite rapidly. Um So you need to keep an eye on their airway as well. And finally, you wanna check their occlusion. Obviously, it's difficult if you're not a dentist, look at this because you're not sure what normal teeth look like, but it's quite easy. You just look at the level of the teeth, are they all on one level or as you can see in this picture, there's an obvious, there's an obvious step. Um Also look at, is there any bleeding from the gums or any tears in the gums. Um and then ask the patient to slowly close their teeth together really slowly. And if they can't, then just say, is there somewhere where your teeth are hitting where they shouldn't? And the patient before you can even see this, the patient can definitely feel it if you've ever had a filling done or you've had braces, you know that if your teeth even move a millimeter, you can feel it in massive detail. So you can imagine if you have a break, the patient will know more than you will know. So just ask them, does it feel funny? Why does it feel what feels wrong? Ok. So that's the examination. Plus I've done. Are there, are there any questions on that? I know it's a kind of a whistle stop tour. But I think if you can do that much, then you're doing very well and um you'll, you'll be able to find the problems very, very quickly. So just let me know if there are any questions in the message box. Ok. Then when we want to investigations, obviously in an ideal world, we should do an examination, then ex investigations will often in A&E busy A&E s and things, things work the other way, the most basic examination uh investigation, sorry that you can get for the teeth in the mandible is an orthopantogram or an O PG. This is a x-ray has done by a big machine goes all the way around your head captures the mandible at the top teeth and makes a two D image of that 3D thing. Obviously, your face is not flat, so it's not as accurate, but it's really good for looking at any dental trauma or mandible trauma. You can obviously see mandible fractures or broken teeth or if we'll come onto this in our next lecture of any abscesses or decay, things like that, it's really good. Um The next common x-ray that we get is apa Mandible. Often it comes up on your request systems. X-ray Mandible. And this is really good at looking at um fractures specifically of the mandible and we'll come up onto why that's important as well. You can see this one, there's an obvious break there. Um Something I should have mentioned, sorry is for both of these investigations, an O PG and an X ray Mandible, the patient has to be able to stand to do it. So if your patient can't stand for any reason, they've got a broken leg, they're unconscious, something, something else, then you'll need to get a CT scan. Instead, they have to be able to stand because the machine can't go round otherwise. OK. Next are facial x rays or officially called occipital mental views. But I think it comes off in most request systems, facial x-rays. So these are two X rays done at two different angles. Um And basically it looks for um fractures or deformities of the mid face and the orbital floor. So it's looking at the cheek bones, the maxilla that you can see here, the eye sockets really well, just looking for any breaks there. Ok. And um of these are done quite frequently because obviously the radiation is a lot less but quite often. These days, we're jumping straight to CT scans, cos these can be very difficult to read. And um it's very hard for A&E doctors to read these and obviously a formal radiological report takes some time. Finally, we have CT facial bones. I think the most important thing for medics to know is if you have a patient who is having a CT head anyway, there is no point then saying, oh and we'll get some X rays just do CT facial bones and CT head because it's really annoying when a little bit is cut off and then they need to be re radiated just to get the facial bones. So just request both of them, it's useful for obviously more complex facial injuries and surgical planning. And if the patient is unconscious or can't stand, then this is probably your best port of call. So now what we're gonna do is I'm gonna give you a brief overview of the common fractures that we see. Um And how, what kind of the it, how quickly you have to escalate them, what the management is, how they're dealt with. Um Just so you have a basic understanding and you can warn your patients as well. So, orbital fractures are really common mainly because your the bones of your orbit are designed to absorb shock. So they break before the eye ball can get damaged. So when you have an impact to this area, it's really common for one of those bones around the eye to break. Um because it actually protects the eyeball, um most commonly there. So there are four walls in an orbit. I know it's round. But anyway, you have the floor of the orbit, which is also the roof of the maxillary sinus. You have the er lateral wall of the orbit, the medial wall which obviously connects to the nose and then you have the superior wall or the roof of the orbit, which is also the base of the brain. So it's really important to know that all of these places have two connections, the eyeball and something else as well. So patients will um commonly present with swelling and bruising around their eye. Um It's essential like we said that you look at the eye in a lot of detail. If there are any concerns about visual acuity or um not reacting to light, it's essential that you call both max facts and ophthalmology for an urgent urge. This is one of the reasons why ophthalmologists will have to come in from off site. Um because it takes only I think when the blood supply goes to your eye, it only takes like half an hour to an hour and it can lead to permanent blindness. So it's really, really important that we check that. Um, sometimes when you have an orbital fracture. So, com most commonly it's the floor of the orbit that's broken. Um, and that's just because of the anatomy. Um, they can also trap the muscles that are, um, the muscles of eye movement. So you can get restricted upward gaze and you can get diplopia in both the lateral gazes. This by itself is not concerning. Um And we'll look into what you would do about that later. So if there are no concerning features from to the or damage to the eyeball, then and um the most of these patients can be referred to Max fax for a review, maybe even a few hours later or the next morning if it's overnight. Um And they are seen again in our outpatient clinic in 5 to 10 days, mainly because the swelling has to go down before a decision is made, worrying features to look for any damage to the eyeball reduction in visual acuity or proptosis. And we'll come on to proptosis a second as well when you send these patients home for Maxx outpatient clinics. Um even though they've been assessed by Maxx just in case they forget or they're unsure, these patients should not blow their nose for six weeks, 4 to 6 weeks. The reason for that is the orbital floor is in contact with your maxillary sinus. And if you put pressure, then that break, that's only small can open up massively. And you can, you often hear about patients coming in. They're like, oh, I blew my nose and then suddenly my face blew up. And that's why because you just introduced all the surgical emphysema. Um, most patients don't tend to have surgery for these. They normally heal by themselves. The reasons for surgery are either they have muscle entrapment if they can't move their eyes fully. And also for cosmetic reasons, such as if one eye looks a lot lower than the other, then it looks very odd once the swelling goes. But that's why we need to wait for the swelling to go to see. Is there a cosmetic defect or a functional defect such as ongoing diplopia or a restricted gaze? Often, once swelling improves all of these things can go back to normal. So a lot of patients don't need anything. If they do need surgery, then surgery is done by cutting for orbital floor fractures, which is the most common. Um a metal plate is inserted underneath their orbit through kind of the underneath your eyeball that cut is made. And nowadays, we're going more to customize plates and things as we can see from these um images. So this is an a a facial x-ray, like we were saying before this one, like I said, it's very difficult to read compared to an obvious CT scan. But you can see that there's what they call a teardrop sign in the left orbital floor. And you can see that th well, this is consistent, this has a break um on a CT scan on a coronal view, it's really easy to see. You can see there's an obvious break here. And often these patients will see they have um a fluid level in their sinus as well because obviously, the blood has gone into the sinus. One last thing to mention about orbital fractures. So very, very rarely. And I've only seen I once happen is when Children have an orbital floor fracture, their bones are more flexible and elastic and they spring back into place and that can trap the soft tissue. This can lead to something called the oculocardiac reflex. It's incredibly rare, but it can cause vomiting and severe bradycardia in Children if that happens, obviously, they need immediate surgery. So that is one orbital fracture. You must treat straight away and call max max urgently to treat it. So if you ever have a kid who's got facial injuries and really bradycardic, just have it in the back of your mind, but it's incredibly rare. So with orbital fractures, we need to be aware of orbital compartment syndrome, which is when something builds up at the back of the eye. Now, normally in trauma, this is blood, but it can also be air if they have severe emphysema or it can be, in other cases, it can be things like tumors and masses that can press behind the eye is this is really important. This is an ma a max fax and ophthalmology emergency must be treated within half an hour. So signs to look out for are loss of red vision, decreased visual acuity, a tense and painful eye proptosis, which is why we're saying it's really important to look from the top is one eye further forward than the other reduced eye movements and a fixed and dilated pupil, the fixed and dilated pupil is a really late sign. So don't rely on that if you have anything, normally, most patients, you'll just be able to see. They've got a really tense and painful eye. And if you do a CT scan on these patients, they can say that there is a risk of a retrobulbar, a hemorrhage or an orbital compartment syndrome. Cos they can see the blood that's gained that's gathered at the back. This needs urgent, urgent decompression to get rid of this blood. And it's done through a lateral canthotomy where basically a cut is main, just on the lateral aspect of the eye to allow all that blood to come through. So just lateral to that eyeball as you can see in this patient, it's obvious this eye is swollen, it's tense, it's proptosed, it just doesn't look quite right. And you can see here how after it is a lateral canthotomy. It really depends on who can do it, depending on what kind of, er, department you're working in. This isn't something that can be transferred to another, a tertiary center because it needs to be dealt with urgently. Commonly, ophthalmology can do it. Max, VX can do it or um, most ed consultants can do it as well. Obviously depends where you work. If it's a trauma center, ed consultants do it more often. Um But it's essential that you find someone, it's not very difficult to do. Once you've done it like once or twice, you can do it. But it's really, really important that you escalate this accordingly. So that's a brief run through of orbital fractures. I think the main takeaway is that needs a thorough, thorough examination just to check there's nothing more serious going on. Um And most of these patients can come back to outpatient clinic for follow up nasal fractures. There's that picture again, obvious deviation and this is what I was saying about looking at septal hematomas. So this you can see this obvious swelling on both sides that needs urgent referral to ent. So, isolated nasal fractures are obviously really common. They're not normally seen by anyone else, they're normally managed um as an outpatient with Ent where they can um see it after soft tissue swelling has resolved. Someone's just asked, how do you perform a lateral canthotomy? Let me just go back one slide and I'll show you it's basically what you do is I can't explain in that much detail because obviously it's hard online and you can look up videos on youtube but you give a little bit of local an er, hoping you can see my cursor. You give a little bit of local anesthetic just on the lateral aspect of the eye and then you open the eyeball up and you just do with a scalpel. You do a cut all the way down to bone, just lateral to the eyeball. And what that does is it releases that one of the ligaments. And that means that there's a connection between the outside world and the back of the eyeball and any blood or anything that's up there, then just seeps through that area and it immediately relieves the pressure. These patients will have a more formal canthotomy done in theaters, but the doing it straight away is key and you can do it. The patient is awake. You just give some local anesthetic. It's not very painful, just a bit uncomfortable because you have to open the eye. Um but it's just a little cut honestly like five millimeters and you just get the ligament and it all uh gets better, but you can look it up on youtube. There's some really good videos I just didn't wanna show up cos I know some people are very squeamish about eyes. So like I was saying, most of isolated nasal fractures go to Ent. Um And after 5 to 7 days, they see if there's a functional or an aesthetic deformity and can be dealt with accordingly if needed. They um So how someone's asked how long after the nasal fracture are they seen in outpatients? So I think normally uh every uh hospital has their own protocol, but I think normally it's within 5 to 10 days. So you just do an ent outpatient referral form 5 to 10 days, cos that's enough time for the soft tissue swelling to go down. So if they need surgery, nasal bones take six weeks to heal. So you have time to do surgery within 2 to 3 weeks of the injury. Um And most of them will have, they put to sleep with a general anesthetic. They have an M UA. So manipulation under anesthesia. So you just push the uh, nasal bone back into the right place. Sometimes you have to put some a stool up into the nostril to get it perfectly aligned and then you have a splint put in the splint, then stays for about six weeks to allow the bones to heal in the right place. Um, and it's really quick surgery. They're asleep for about 5 to 10 minutes and it's all done. Um, like I said, septal hematoma is an emergency and needs urgent incision and drainage cos it can block off the, off the blood supply to your septum and it can become necrosis if the patients have multiple facial fractures. So a nasal fracture and something else, Zoma fracture, mandible fracture, anything else in the face these are normally dealt with by Max Fax. Um because Ent don't do other facial fractures. So if you have a patient who's got loads of different things going on and they're coming to Max Fax Clinic anyway, or being reviewed by Max Fax, they don't need to be seen by ENT as well. Normally, because the max fax, the surgeons can deal with the nose as well. Ok. Next, we'll go on to mandible fractures. These are by far the most common ones you normally see apart from nasal fractures, but nasal fractures are very mild and nothing to really worry about. So, signs and symptoms of mandible fracture. So it's patients have obvious jaw deformity. Once you've seen a mandible fracture, it's really obvious you'll never miss it. It's hardly ever missed. Cos it's the patient will just tell you I've broken my jaw. Normally. They have pain and swelling in the jaw and altered occlusion. So the d the patient will say my teeth aren't meeting as they should. I can't bring my teeth together for some reason, numbness or paresthesia of the inferior dental nerve. So that's in the mandibular branch of the trigeminal. So let's say I've got weird feeling in my lip, a numb lip. My chin feels odd and that's because the inferior dental nerve runs just in your mandible. So if you break it, you always disturb the inferior dental nerve or when you have an exa look at the inside of their mouth. If they've got a gingival tear bleeding around any of the teeth in the lower jaw or like you said, the floor of the mouth has sublingual hematoma. So the main thing for mandible fractures from um a clerking or a triage perspective is that all isolated mandible injuries. If they're not having a CT scan, they must get two radiographic views. So that's an O PG and an X ray mandible. And that's because because of the mandible shape, it's U shaped, it's really, really common for it to be fractured in two places. And often if you do just one view, you can miss the fractures. Um Mao many, many, I think over 50% of mandible fractures will be fractured in two places. So when the patient is really worried that I only got punched once, why is my mandible broken in two places? It's because the way your mandible takes impact is that it goes across the whole thing. So you often if you get punched on the right side, you break the right side and the left side of the jaw really common. So all nearly all mandible fractures. And I think for you guys, it's learning just all mandible fractures need urgent max fracture review and they must be admitted for IV antibiotics. IV analgesia and you keep them nil by mouth for an orif or open reduction, internal fixation under general anesthetic, the way that's done in most places they go on the e list, the emergency list, um, they're put to sleep and basically a cut is made on the inside of their jaw and plates are put to fix their mandible in the right place to ensure it heals appropriately. Um, often patients, teeth are never quite the same again, cos it's impossible to get it. Exactly, exactly the same. Um But we do the best that we can. The reason that why these fractures are all admitted and a lot of the other fractures we talk about can go home is because if the mandible is really not secure and can be floppy, can fall back. They have a sep uh sublingual hematoma, it's an airway risk. Um So you have to ensure that they get admitted because if they go home and the airway goes, it's obviously an issue. Another reason is because it's all mandible fractures will be open fractures. So they're exposed to the outside world or the mouth in this case, unlike other fractures in the rest of the body where there can be closed fractures. So the maxilla, the zygoma, the legs, the arms, things can not break skin, all mandible fractures, break skin or the mucous membrane. So that means they're a big a bacterial infection risk. Um And that's why all patients have antibiotics. IV antibiotics and need urgent surgery. Obviously, if they're not getting surgery straight away, just make sure they keep to a really soft basically and no chewing diet, um just drinks. Um But otherwise they should be kept, kept i by mouth. So we can see this is an O PG. Um And uh there's an obvious break here, obvious crack there in the mouth. It would be really obvious, there'd be a step, big step there and also bleeding and obvious pain where you palpate in that area. Like I was saying, this is an X ray mandible. And the reason this is really important is if you can see there is a break, obvious break on the right side of the patient here, but really easily can be missed. There is also a break on the left top jaw here, right at the top in the Honda. So where your TM near your T MJ? And why that's important to get two views. If you can see from the er op Gx ray, it doesn't capture that area very well because it's a two D image. And often if there's a little break there, it can be really easily missed. Um So it's essential that you get two views to check for any fractures at the top of the jaw as well as the bottom of the jaw because often these are missed and it's not as easy to see because there's no obvious bleeding. You can't see them inside the mouth and things like that. So just ensure that you get two views. If you're not getting a CT scan, often radiographers will say you don't need two views. Why do you need it? Just explain to them all man, all mandible fractures need to have two views. OK. So that Mandible fractures um and a brief overview of how we treat them. If you do ever get a chance to sit in on a uh a fixation of a mandible. It's really interesting. It's a really quick procedure and it's really nice how it comes back together. It's almost like a puzzle, it just fits back together. Um After they have their, I just quickly go back after they have their mandible fixed, same as the neck nose fractures. They take six weeks to heal fully. So you basically tell the patient you can't chew hard foods, no eating steaks or anything for six weeks because you can dislodge that fracture. And once it's healed, patients can go back to eating as normal. These plates are never removed in mandible fractures unless they get infected. Um You don't, you can normally just live with them. So next, we'll go on to mid face fractures. Um And this is something that is kind of classified by someone called Le Four. I think the story is he was a French guy. He basically got loads of skulls, threw them off balconies and saw how they broke and what he found is they all tend to break in a similar way because there are areas of weakness in your skull. And it's probably for some sort of evolutionary reason, but most midface fractures can be classified by this le four classification. Only thing to remember is obviously humans are not that simple, they often have other fractures going on. So you normally have a LeFort and a mandible or le four and a Zygoma or something else happening. So a le four fracture involves separation of the mid face from the skull base. And in the in er radiological terms to have this, you must have a fracture of the pterygoid plate because that's what connects your mid face to your skull. You're not gonna be able to see this, but you'll see it reported a lot in X ray and CT scans and you can see it on this image that, that pterygoid plate has just broken but nothing to worry about for you. So le four fractures, um le 41 fracture is basically when the maxilla has detached from the top. So it's like a straight line. The maxilla is really mobile. That's what's happened. Le 42 is when there's a horizontal fracture line across the bridge of the nose and then down. So it's like a pyramid shape and that means the whole mid face is kind of er mobile. The 43 only happens in really high impact injuries and it's when there's a really high horizontal fracture through the naso frontal butters, the orbital floors and the Zygomatic frontal sutures. So basically, it's complete craniofacial dysfunction. So at the top of your head, it's completely detached from your face. Um, and this is obviously a lot more severe than the other two. The other two can normally go home again, be seen in outpatient. So just be warned of any er, red flags to look out for, but most high impact injuries will need to stay in because of the risk to the airway. So, Zygomatic fractures. So there are broadly two types of Zygomatic or cheek bone fractures. The thing to remember is um I don't know how much you'll know from, remember from your facial anatomy. But the Zygoma is a really complex bone, it's actually got four connections to four different bones. Um often they're called tripod fractures, but I think there's actually four breaks. So you can get a Zygomatic complex fracture, which is where you fracture your Zygomatic arch, the inferior orbital rim and the lateral orbital rim. So you can see here that whole Zygomatic bone has been fractured or more commonly, you'll see an isolated Zygomatic or cheek bone, a Zygomatic arch or cheek bone fracture. And this is normally from like a sports football injury being elbowed to the face, obviously, that bone, as you can see on the CT scan really thin, really prone to breaking. Um It happens really commonly. Um these patients are often, you can often see the fracture because they have a flattened cheek bone and sometimes it's hard for you to see. But the patient will say my cheekbone isn't right. Like I look not right and they'll know and you can tell. And again, most of these patients can be, they need to be seen by max Vax. But most of these patients can be discharged home and brought back to Max Vax Clinic in 5 to 7 days. Again, surgery is done for functional or aesthetic reasons. Um Most Zygomatic complex fractures are treated unless they're very minimally displaced. But uh cheek bone fractures sometimes are left alone if they do need fixing. It's a really simple procedure. Um It's called something called a Gillies lift where you actually make an incision in the temple and the instruments brought down and you just kick it out. Um Again, these are things that can wait a few days. So it's not an urgent thing. Um unless you're concerned about the eye or anything else or the mandible not opening fully. Next, we'll go on to frontal sinus fractures. So you can see this is an axial view of a CT scan. The frontal sinus is obviously in your forehead, you have an anterior table. So that's the bit at the front, then you have air, then you have a posterior table. The posterior table obviously is the entrance to your brain. So if you have a posterior table fracture they need urgent neurosurgical input. Most of the time they won't do anything but you need to put them on high dose antibiotics and things. Anterior um table fractures can normally be left for a few days. They might need some antibiotics still. And it's normally more of a cosmetic thing where they need to be fixed. Um But really, really important that you look out for these and escalate to neurosurgery if needed. But often the CT scan will say it's a posterior table fracture, refer to neurosurgery. So that's a brief run through of facial fractures again. As long as you can identify, what do you need to image and what do you need to refer? That's really all you need to know. Um And then if you ever do a max fax job in the future, you'll learn a bit more about how they're treated. Let me know if there are any questions about that. Otherwise we'll move on to facial lacerations. Sorry, I know it's a really long lecture and we're going through everything quite rapidly. There's just a little whistle stop tour. So facial lacerations, I'm sure you guys have seen loads of these really common after falls, assaults, trauma, anything. Um and majority of these facial lacerations can be dealt with by an E A&E doctor or an ACP in A&E the reason the questions you need to ask to see who deals with this are, where is the wound? And are there any functional or aesthetic implications. So for example, places like the eyelids, um nasal lacerations involving the cartilage, um lacerations, crossing the vermilion border of the lips. So where lip becomes skin, um and anything in the neck will need specialist input for sure. Um Obviously, bigger lacerations will also need specialist input or anything where will come on to it. When did the injury occur? This is important because injury some times people come in five days later and o obviously, there's a high high infection risk at that point is the wound clean or contaminated. So what exactly happened? Have they got glass fragments and there's there mud in there. What what's happened really important? Is there any damage to underlying structures? So any vasculature? So is there uh arterial bleeding, any nerves that have been damaged are really important in this scenario that they have lacerations to check the facial nerve, to check all the movements of the face to check nothing's been cut and other structures. The main one to worry about is the parotid duct. So your parotid gland sits, if they have a deep laceration there and you cut the duct, they can't produce saliva into the mouth and they'll get massive swelling. So the way to check that is just to look inside the mouth to check they're producing saliva. Is there any tissue loss? Um Can the wound be closed on local anesthetic or as formal exploration and debridement even under general anesthetic now, these are wounds that are obviously much larger, there's damage to underlying structures or they're heavily heavily contaminated. For example, they've fallen over, there's mud everywhere, those ones that need proper cleaning. And obviously, are there any underlying fractures? Because you might just do everything at the same time? There's no point patient having two general anesthetics. Um, so closing facial lacerations, there are, these are the options really, you can either do nothing. Loads of facial lacerations, really superficial, don't need to touch them. They'll heal by themselves, steri strips. If they're really superficial, you can just pop a steri strip on obviously, in the face, some areas are a bit more difficult. You obviously can't put it near the lips or near the eyes. Glue. I don't re recommend glue in the face because it scars really really badly. The only situation where I would use glue for facial lacerations are in really young kids who are never gonna cooperate and they're not big enough to warrant a G A or sedation. Finally suturing them under local or general anesthetic. Um It's really, people are often scared of suturing the face because of the aesthetic implications. And if you do have a max fax person on site, it's really beneficial for them to do it because obviously they're experts. But a lot of A&E doctors are really competent, they're really good at doing it. The only areas are the ones that I mentioned the eyelids. Um The vermilion border, uh and the neck and the nasal cartilage are the ones that definitely need specialist input after a patient. Has any of these things done? We recommend that the wound is kept dry for 3 to 5 days and that's because of the risk of infection and scarring um in the face. Normally, we try to use non resorbable sutures because they just give a better aesthetic outcome. These sutures need to be removed by a GP or outpatient department in 7 to 10 days. The only thing I will say is with COVID, things are obviously going back to normal. Now, we did start using a lot more resorbable sutures in the face because the risk of the patient coming back was too much. Um And a lot of patients, if they say I don't have a GP, I'm never gonna get to my GP, then maybe just use a resorbable suture. Just use your clinical judgment. And the most important thing is to make sure that we safety net, these patients so return if there's any signs of infection. So redness, swelling, warmth, pus discharge anything like that. Majority of these don't need antibiotics to go home with. Um, but the few that do are heavily contaminated wounds, any bites, that's human bites, dog bites, any animal bites. Um, or if you're just concerned, they're immunosuppressed, they're poorly controlled diabetic, something else that makes you worry. The good thing about the face is because of the vasculature is so strong, the infections are much less likely than the rest of the body. The other thing to keep in mind is with any wounds. Just think about tetanus prophylaxis and whether they need a top up, um, when you're cleaning these wounds, just make sure that you thoroughly cleaned them with either Saline or if they're very contaminated with iodine and saline. Um, and just use your clinical judgment on what needs to be followed up what needs to be done by a specialist and what can be done by like an ACP very, very quickly cos like I'm wary, we're running out of time. We're just gonna go through dental trauma. The reason I brought this up is because as we all know, NHS dentistry is kind of doing very badly. People are finding it really difficult to find an NHS dentist, especially in an emergency. So more and more frequently these patients are presenting to GPS and A&E departments, dental trauma while it seems minor can have really life changing, physical and psychosocial consequences and early management can significantly improve prognosis. So the main thing I want you to remember is if there is a patient who has avulsed their tooth, so the whole tooth has come out, but the tooth is also in one piece, either pop it back in yourself or tell them how to store it. So someone else can pop it back in. So to store it, they need to store it in a glass of normal cow's milk that can make sure that the tooth stays hydrated before they can get to an A&E department or to a dentist. If you're gonna reimplant it yourself, which is the ideal thing to do, do it as quickly as possible. You hold the false tooth by the crown. You rinse the, it only visibly contaminated with either saline or milk and then you orientate it and put it back in the socket. Then you just get them to bite on a piece of gauze or something to stabilize it and then contact your nearby max fax department or on call dentist or an emergency dentist for splinting. Make sure we do not, sorry type of that. Do not reimplant baby teeth, seeing it happen. It's not a good idea. Obviously don't reimplant them. Um The best thing to do to how to get through to an emergency dentist for your patients. If they don't have Maxx nearby or Maxx can't do it is to call NHS 111, explain what's happened and they'll direct you accordingly. Most regional areas have an emergency dentist who works at least within hours. So that's very useful if they lose their tooth and you can't find it. The patient can't find it. They don't know what's happened to it. They don't know if they've swallowed it or not. Then I would always recommend doing a chest X ray to make sure they haven't breathed it. In. These are just some other dental trauma things that can happen. So teeth can move in all positions, get fractures, you can get concussions. All dental trauma should really be discussed with the Maxx or an emergency dentist. They can just be contacted, like I said through NHS 111 things are really tricky right now with dentistry and your patients will always complain. But obviously there's only so much we can do and there's only so much equipment in a hospital that max vax can do. Sometimes you just need to go to a dentist. So in conclusion, facial trauma is really common, always discuss any cases you're unsure about with your senior or max sa on call. Thorough history and examination are key knowing when to escalate and safety netting is really important, especially as many of these patients are seen in outpatient clinics. It's really important to say come back. If there are any signs that your eye sign is getting worse, you can't breathe. Um You've got signs of infection, you've got temperature, unwell, bleeding pus, anything like that. Um make sure that you uh safety net the patients appropriately. Finally, just some references. So there's some good books, there, some images from radio pia if you're interested in max fax at all. There is this second resource I've written. It's oral and maxillofacial surgery. An illustrated guide is available for free through the British Association of Oral and Maxillofacial Surgeons just online and it's really, really good goes through everything in a really basic detail and it's really good for people who are just getting an introduction into facial trauma and uh just general dentistry and Max Fax. So that's the end of the presentation. So we've, it's been a long, long lecture. Um Please let me know if you have any questions. Um Otherwise if you come up with anything or you're interested even in Max Fax as a career or exploring it a bit further, just email us at mind the bleep and we can help uh look into this. Um We've got two more sessions in this series, I think both are next week. So we're gonna look at infections um which again because of the state of NHS dentistry are unfortunately becoming more common. Um And also then after that, we've got kind of a miscellaneous one looking at loads of different things. So, yeah, any questions, just pop them in the chat. Otherwise, thank you very much for listening. I'll hang around for a few more minutes and just let me know if um there are any questions that you have? Thank you. Oh, and finally, I should say you can get a certificate for this, which is really good for any surgical applications. Um and that you've shown an interest in surgery and also please give some feedback if you can. Uh So Lauren has just asked, would you reimplant the evolve tooth if you suspect a fracture or wait till the imaging has been performed. I would say if the tooth is fully intact, unless they have massive massive facial trauma, just reimplant the tooth. You can't do anything wrong. If there's a fracture, you can only disrupt the fracture a little bit more. Um, so just pop it back in and it's not stuck in place until it's splinted. So worst case they'll get to a dentist or a max fax doctor and they'll say, oh, that's not put in, right, let me take it out and put it back in. So the best thing you can do is put it back in. If a tooth is out of the mouth by, I think half an hour to an hour, the prognosis goes significantly down and you know how much it costs to get a tooth replaced. You can save patients like thousands and thousands of pounds'. It's very good. Uh It's uh Jian, why is it called a tripod fracture? So, basically, it's a three, the Zygoma has three main uh connections which are in your temple, the maxilla and at the back here and most patients present with a break in three places. Um And then that's why the thing is that uh Zygoma actually have one more connection which is more inside. Um But you can't see that one very obviously. So it's like a tripod three bits break. Uh Where do we complete the feedback form? I think it's just on meal. So once you finish this, you can just say I attended this and just fill out the feedback. I think it's in the chat function on the side. Actually, there's a feedback section. Perfect. Um Thanks for all your um nice comments. Er I'll stay for a few more minutes just in case anyone has any more questions. Um Otherwise feel free to email me um through my info at mind the bleep.com or I'll be doing the sessions next week. So you can always ask me then. So if you reimplant the tooth and they're a mandible fracture and can't bite on the gauze, are there any tips to keep the reimplanted tooth in? So most times your bottom teeth don't actually get evulsed because they're protected by your top teeth. So majority of ones that get lost are the top teeth. I wouldn't worry so much about the bottom teeth cos you can see on me as well if you lose your bottom teeth, that's not the end of the world. I would just put it back in and don't get them to bite, just put it back in and just tell them, keep your mouth open and it's fine cos they shouldn't be eating anyway. Um, the most commonly er evolved teeth are the two front incisors and they have the most psychological impact. I think I read something crazy like it's the same as losing a leg or something for some people, which is insane. But that's apparently how people feel. So, don't worry so much about the bottom teeth, but if they do have a mandible fracture, just put it back in and just let it be. Hopefully, that answered that question. No worries. Thank you very much for all your support. I hope to see some of you guys next week for the rest of our things. Otherwise all the sessions next week will also be recorded. Um So just keep an eye out. We're also gonna upload some more articles about max folks to the mind the bleep website. So keep an eye out for those and I am obviously biased, but I would say it's an excellent career. So if this is uh all sparked your interest, then just let me know and I can give you some guidance on how to get some more exposure to max fax and uh just trauma in general. Perfect. OK. Take care. Enjoy the rest of your evening. Bye.