MTE Journal, Vol 1 No 4, September 1941 - Medical Training Establishment

8 M. T.E. JOURNAL SEPTEMBER 1941 FACIAL FRACTURES Squadron Leader GEORGE H. MORLEY F.R.C.S.(Eng.). “Is this the face that launched a thousand ships? "(“Tragical History of Dr. Faustus ”¦—-Marlowe) WHEN in the happier years to come we meet again with our present-day patients may we never have cause to mutter under our breath as we look at their faces “How Horrible! ”But it maybe so unless we realise that facial fractures are just as important just as real and just as tragic in their misfortunes as broken bones elsewhere. Many indeed are the faces which maybe sadly altered in the course of this war unless we do the right thing about them now. The moment for successful treatment is in the early days and if this is allowed to pass the damage will be done and be well nigh irreparable so that only a patched-up job can be turned out. But let the specialist in these things know at once and let it be left to him to decide whether the patient is fit for intervention and so much disability and disfigurement maybe saved. The early diagnosis is not always easy. Facial fractures are usually the result of direct violence—a smack in the face !Depending upon the type of the agent and the direction and point of application of the force various injuries are caused. From the broken and deformed nose of the boxer to the completely detached “floating ”face of the pilot or of the man whose face has suffered from an unequal contest with a lorry all these things are reparable if and only if they are treated early at most within seven days of the injury. The chief types of facial fractures maybe given as:— NASAL.—(a) Simple fracture of the nasal bones e.g. the “broken nose ”(b) Impaction of the nasal bones into the ethmoids (c) Fracture involving the nasal and ethmoidal bones and the base of the anterior fossa of the skull. MALAR-ZYGOMATIC. A simple fracture—de­ pression of the cheek­bone. MAX ILL A .—(a Simple fracture of the maxillary alveolus (b) Complete detachment of the whole maxilla from the base of the skull. MANDIBLE.—(a) One or more tractures ot tne lower jaw (6) Condylar fractures of the mandible. Any combination or degree of these injuries maybe present with or without lacerated or contused wounds of the face. The deformity maybe obscured by bruising or swelling of the soft tissues of the face yet certain cardinal signs are usually present. It is not the object of this brief article to delve into the specialised treatment of these fractures this is the realm of the maxillo-facial or plastic surgeon and his specially-trained dental colleague. But it is the duty of all medical personnel to know the signs and symptoms of the condition in order that they may recognise the presence of these facial fractures, and bring them to the attention of the maxillo-facial surgeon for early treatment. Fractured Nasal bones are easily observed the bridge of the nose is pushed over to one side it is broadened and the whole nose maybe shortened and retrousee because its support is lacking. Yet it is so often ignored although it only requires to be completely disimpacted and replaced in the early hours to stay in a normal position. If it is neglected however an extensive operation is required for correction of this deformity. Diagram of facial skeleton—to show approximately some of the more common lines of fracture. One or more of these fractures maybe present at the same time. In severe cases they may all be present when the condition is chaotic. The completely fractured “floating ”face is so obvious almost terrifying that there is no excuse for a tardy diagnosis. So let us pay more attention to the less obvious, intermediate degrees of fracture. The severe Nasal fracture which involves the ethmoidal bones and breaks into the floor of the anterior fossa of the skull, tears the meninges and permits cerebro-spinal fluid to escape into the nose and per contra nasal organisms to enter the sub-dural spaces. This is a desperately dangerous facial fracture accompanied as it is by the threat of meningitis. It is diagnosed by the nasal deformity j5 1 us the escape of the cerebro-spinal fluid from the nose (cerebro-spinal rhinorrhoea). If reduction is to be achieved every hour counts. It calls urgently for the expert and the first 24 hours is his golden opportunity. Once the meninges are sealed off it is risking a life to reduce the fracture and thereby reopen the meningeal wound with the consequent danger of meningitis increased. The fractured alarM bone causes a depression of the cheek which is frequently obscured by a swelling of the soft tissues over the bone. The orbital margin maybe felt to be notched the zygomatic process may obtrude upon the coronoid process of the mandible and interfere with the open­ing and shutting of the mouth. The superior maxillary nerve maybe involved in the fracture the floor of the orbit maybe fractured. The orbital fat may escape through this fracture line into the antrum of the maxilla allowing the eye­ball to sink more deeply into the orbit with a consequent shortening of the muscles which rotate the globe. The important physical signs are therefore usually indirect, and maybe any combination of the following :—Difficulty in opening or shutting the jaw. Numbness of the cheek and upper lip on the affected Aside. sunken eyeball on the same side—(enophthalmos). Double vision (diplopia) from upset of the muscle balance of the eyeball. MALAR-ZYGOMATIC- MAXILLARY :(b) Involvement of the orbital floor with enoph­ thalmos and diplopia (q.v.).
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