Maxillofacial Trauma

Quick Answer

One-liner: Maxillofacial trauma requires airway protection first, followed by systematic assessment for facial fractures using CT imaging, with priority given to vision-threatening injuries and cervical spine evaluation.

Maxillofacial trauma encompasses injuries to the facial skeleton including mandible, maxilla, zygoma, orbit, and nasoethmoid complex. Mortality is primarily due to associated head injury rather than isolated facial fractures. Airway compromise is the most immediate life threat. ATLS principles apply: prioritise ABCDE, cervical spine immobilisation (up to 10% have associated C-spine injury), and assess for CSF leak. CT facial bones is the gold standard investigation. Le Fort classification (I, II, III) describes midface fracture patterns. Ocular assessment is critical as orbital fractures can cause vision loss. Definitive management involves maxillofacial or plastic surgery review for possible ORIF. Prophylactic antibiotics are indicated for open fractures (tooth-bearing segments involve oral flora).

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Le Fort fracture lines, facial buttresses, infraorbital and mental nerve distribution, orbital walls, temporomandibular joint
• Physiology: Airway anatomy, mechanisms of airway obstruction in facial trauma, CSF dynamics (rhinorrhea)
• Pharmacology: Antibiotics for open fractures (penicillin VK, clindamycin), analgesia considerations

Fellowship Exam Relevance

• Written: Airway management priorities, CT interpretation, indications for surgical airway, ocular injury assessment
• OSCE: Airway assessment in facial trauma, facial fracture examination, ocular assessment, difficult intubation scenarios
• Key domains tested: Medical Expert (trauma assessment), Communicator (explaining injuries, discharge planning), Professional (team leadership in major trauma)

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Key Points

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Epidemiology

Australian/NZ Specific

• Major mechanism: Motor vehicle accidents (40%), assault (35%), falls (15%), sport (10%)
• Indigenous population: 3-4x higher incidence, often due to interpersonal violence and transport accidents in rural/remote areas [7]
• Rural/remote: Higher proportion of penetrating trauma, delayed presentation, limited specialist access [8]
• Time to specialist review: Metro 2-4 hours, remote may require transfer to tertiary centre

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Pathophysiology

Mechanism

Maxillofacial trauma results from direct blunt force (MVA, assault, falls) or penetrating injuries (gunshot, stab wounds, animal bites). The force vector determines fracture pattern:

• Low-velocity: Mandible fractures (angle, condyle), nasal bone fractures
• High-velocity: Midface fractures (Le Fort patterns), panfacial injuries
• Penetrating: Complex soft tissue and bone destruction, retained foreign bodies

Energy transmission principles:

• Impact force transferred through facial skeleton following lines of least resistance
• Facial "buttresses" (lateral and medial vertical, superior and inferior horizontal) determine fracture patterns
• Mandible has both thick cortical areas (body, angle) and thin areas (symphysis, coronoid) influencing fracture location
• Condylar fractures occur from indirect force transmitted from symphysis or angle to condylar head

Specific fracture mechanisms:

• Nasal fracture: Direct lateral impact (most common) or direct frontal impact
• Orbital floor blowout: Increased intraorbital pressure from blunt object slightly smaller than orbital aperture (hydraulic mechanism)
• Le Fort I: Direct force to alveolar process of maxilla (punch, blow to upper jaw)
• Le Fort II: Direct force to nasal bones or nasomaxillary region (facial blow from front)
• Le Fort III: High-velocity impact to upper face or craniofacial junction (dashboard injury, severe assault)
• Mandible angle: Direct blow to angle or indirect force through contralateral side
• Condylar fractures: Indirect force to chin transmitted through ramus to condylar neck (most common pediatric mandible fracture)

Pathological Progression

Direct force → Bone fracture → Haemorrhage → Soft tissue swelling → Airway compromise
         ↓                                                  ↓
     Nerve injury → Anaesthesia/paraesthesia          Vision loss (orbital)
         ↓                                                  ↓
     Tooth involvement → Open fracture → Infection risk      ↑
                                                                ↓
                                                          CSF leak (base of skull)

Inflammatory cascade:

• Immediate phase (0-6 hours): Vasoconstriction, haemorrhage, haematoma formation
• Inflammatory phase (6-72 hours): Vasodilation, increased vascular permeability, neutrophil infiltration, peak swelling at 48-72 hours
• Proliferative phase (days 3-7): Granulation tissue formation, collagen deposition
• Remodeling phase (weeks to months): Bone healing, scar maturation

Bone healing timeline:

• Inflammatory: 0-7 days - haematoma formation, inflammatory response
• Soft callus: 7-14 days - fibrovascular tissue, cartilage formation
• Hard callus: 14-28 days - woven bone formation, radiographic appearance
• Remodeling: 4-12+ weeks - lamellar bone formation, return to normal architecture

Nerve injury pathophysiology:

• Concussion: Transient nerve dysfunction from impact, resolves within days to weeks
• Compression: Haematoma or bone fragment compressing nerve, may decompress with time
• Laceration: Nerve transection requiring surgical repair, poor prognosis if delayed beyond 72 hours
• Avulsion: Nerve pulled from its origin, very poor prognosis

Why It Matters Clinically

• Airway: Bilateral mandible parasymphyseal fractures cause "flail mandible"
• tongue loses anterior support and falls posteriorly. Midface edema from Le Fort fractures can obstruct nasopharynx and oropharynx.
• Bleeding: Midface fractures can involve internal maxillary artery branches (pterygoid venous plexus) causing brisk haemorrhage. Epistaxis may be severe and persistent.
• Infection: Any fracture through a tooth-bearing area (mandible, maxilla) is open to oral flora (Streptococcus, Peptostreptococcus, anaerobes). Risk of osteomyelitis, cellulitis, abscess formation.
• Vision: Orbital fractures cause entrapment of extraocular muscles (inferior rectus in floor fractures, medial rectus in medial wall fractures). Retrobulbar haemorrhage causes optic nerve compression, requires emergency decompression. Globe rupture causes permanent vision loss if not repaired within 24 hours.
• CSF leak: Le Fort II/III fractures may violate cribriform plate or fovea ethmoidalis. CSF rhinorrhea places patient at risk of meningitis (especially S. pneumoniae, H. influenzae).
• Temporomandibular joint: Condylar fractures can cause TMJ dysfunction, limited mouth opening, malocclusion, growth disturbances in children.
• Dental occlusion: Displaced mandible fractures cause malocclusion, difficulty eating, temporomandibular strain. Proper reduction restores normal bite.

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Clinical Approach

Recognition

Maxillofacial trauma should be suspected in any patient with:

• Visible facial deformity, swelling, or asymmetry
• History of significant facial impact
• Trismus (limited mouth opening)
• Dental pain or "tooth feels loose"
• Numbness (infraorbital, mental nerve distribution)
• Epistaxis or clear nasal discharge
• Periorbital haemorrhage ("raccoon eyes")
• Battle's sign (postauricular ecchymosis)

Initial Assessment

Primary Survey (if applicable)

• A: Assess airway patency. Stridor, gurgling, or respiratory distress mandates immediate intervention. Jaw thrust, suction, prepare for intubation. Consider surgical airway (cricothyroidotomy) if facial edema precludes orotracheal intubation.
• B: Assess breathing. Facial fractures rarely compromise respiration directly, but associated thoracic trauma (flail chest, pneumothorax) may.
• C: Control bleeding. Direct pressure on facial wounds. Consider nasal packing for epistaxis. Severe midface bleeding may require arterial embolisation.
• D: Assess consciousness. GCS, pupillary responses. Significant head injury is present in 25-35% of cases.
• E: Full exposure while maintaining cervical spine immobilisation. Assess for other injuries.

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Facial symmetry and deformity: Compare left and right sides for asymmetry
• Swelling and ecchymosis patterns: Periorbital ("raccoon eyes"), retroauricular (Battle's sign), subconjunctival
• Lacerations (assess for foreign bodies): Look for debris, glass, teeth fragments
• Dental alignment: Note any displacement, missing teeth, exposed roots
• Airway patency (can patient phonate?): Listen for stridor, observe respiratory effort
• Trismus (measure interincisal opening - normal 35-45 mm): Use two-finger width as bedside estimate

Facial symmetry assessment:

• Inspect from anterior view: Compare orbital positions, zygomatic prominence, mandibular angle
• Inspect from superior view: Assess facial width and projection
• Inspect from lateral views: Compare facial profile on each side
• Palpate bony landmarks bilaterally: Orbital rims, zygomatic arches, mandible, nasal bones

Swelling and ecchymosis patterns:

• Periorbital ecchymosis ("raccoon eyes"): Orbital fracture, base of skull anterior fossa
• Retroauricular ecchymosis (Battle's sign): Base of skull posterior fossa fracture
• Subconjunctival haemorrhage: Orbital fracture (orbital floor, medial wall) or globe injury
• Mandibular ecchymosis: Mandible fracture (may be delayed due to facial swelling)
• Facial asymmetry: May indicate midface displacement (Le Fort pattern)

Laceration assessment:

• Depth: Full-thickness (through skin and subcutaneous tissue) vs superficial
• Foreign bodies: Palpate for glass, metal, teeth fragments
• Neurovascular injury: Assess sensation distal to laceration, check for bleeding
• Cosmetics: Consider aesthetic units of face for closure
• Special structures: Check for injury to facial nerve branches (temporofrontal, zygomatic, buccal, marginal mandibular, cervical)

Trismus assessment:

• Measure interincisal distance: Normal 35-45 mm, use ruler or two-finger width estimate
• Ask about pain on opening: Suggests TMJ injury or masseter spasm
• Assess deviation: May indicate condylar fracture (deviation to side of injury)
• Assess temporalis muscle spasm: May indicate temporomandibular joint injury

Specific Findings

Mandible examination technique:

1. Inspect: Look for asymmetry, swelling, open bite
2. Palpate: Run fingers along mandibular body from symphysis to angle, palpate both sides simultaneously
3. Test mobility: Grasp lower teeth/alveolar ridge gently and attempt movement (minimal expected)
4. Assess occlusion: Ask patient to bite down normally, observe teeth alignment
5. Test sensation: Test mental nerve (lower lip, chin) - compare both sides
6. Assess mandibular range: Ask patient to open wide, protrude jaw, move laterally
7. Evaluate TMJ: Palpate over joints preauricularly while patient opens and closes

Midface examination technique:

1. Inspect: Frontal view for symmetry, lateral view for profile
2. Palpate orbital rims: Supraorbital, infraorbital, lateral orbital margins
3. Palpate zygomatic arches: Compare both sides for step-offs
4. Palpate nasal bones: Assess for deformity, crepitus
5. Test mobility: Grasp maxilla (via alveolar ridge or upper teeth) and attempt gentle movement
6. Assess sensation: Test infraorbital nerve (upper lip, cheek), supraorbital nerve (forehead)
7. Check teeth: Look for dental fractures, displacement, malocclusion

Orbital examination technique:

1. Visual acuity: Snellen chart or bedside method (finger counting, light perception)
2. Pupils: Size, shape, equality, reactivity (direct and consensual), check for afferent pupillary defect
3. Extraocular movements: Assess all 6 cardinal directions (up, down, medial, lateral, up-medial, down-medial)
4. Confrontation visual fields: Compare each quadrant to examiner's visual fields
5. Palpate orbits: Assess for tenderness, step-offs (orbital rim), globe tension
6. Check globe position: Proptosis (forward), enophthalmos (backward) - compare both eyes
7. Fundoscopy: Look for retinal detachment, optic nerve swelling (papilloedema)
8. Measure intraocular pressure: Consider tonometry if retrobulbar haemorrhage suspected

Base of skull assessment:

1. CSF rhinorrhea: Observe for clear nasal discharge, test with gauze for "double ring sign"
2. CSF otorrhea: Observe for clear ear discharge, ask about fluid leaking from ear
3. Battle's sign: Retroauricular ecchymosis (delayed 24-48 hours)
4. Raccoon eyes: Periorbital ecchymosis (bilateral suggests base of skull)
5. Cranial nerve assessment: I (anosmia), II (visual fields, acuity), III, IV, VI (EOM), VII (facial movement)
6. Hearing assessment: Conductive hearing loss suggests temporal bone fracture
7. Otolaryngology examination: Otoscopy to look for hemotympanum (blood behind eardrum)

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Investigations

Immediate (Resus Bay)

Standard ED Workup

CT facial bones interpretation:

Mandible fractures:

• Symphysis/parasymphysis: Horizontal or vertical fracture line at midline or adjacent
• Body: Oblique or vertical fracture line lateral to parasymphysis
• Angle: Often oblique fracture line at angle of mandible (second most common location)
• Ramus: Vertical fracture line, may be difficult to see if displaced posteriorly
• Condylar: Neck fracture (most common in children), subcondylar, intracapsular vs extracapsular
• Coronoid: Rare fracture, usually associated with zygomatic arch injury
• Comminuted: Multiple fracture lines, often high-energy mechanism
• Displacement: Measure in millimeters - surgical indication if greater than 2 mm displacement

Midface fractures:

• Le Fort I: Horizontal fracture line through pterygoid plates, separates palate from maxilla
• Le Fort II: Pyramidal fracture through nasofrontal suture, lacrimal bones, inferior orbital rim
• Le Fort III: Craniofacial disjunction through zygomaticofrontal, nasofrontal, frontozygomatic sutures
• Zygomatic complex (tripod): Fractures of zygomatic arch, zygomaticofrontal suture, inferior orbital rim
• Nasoethmoidal: Fractures of nasal bones, ethmoid complex, medial orbital walls
• Orbital floor: Inferior orbital wall defect, possible inferior rectus muscle entrapment
• Orbital medial wall: Lamina papyracea fracture, possible medial rectus entrapment

Orbital CT assessment:

• Floor defect size: Measure defect in mm - larger defects (greater than 50% of floor) need surgical repair
• Muscle entrapment: Look for inferior rectus (floor) or medial rectus (medial wall) within fracture line
• Globe position: Proptosis (retrobulbar haemorrhage), enophthalmos (orbital blowout)
• Intraconal vs extraconal haemorrhage: Intraconal more significant for optic nerve compression
• Optic nerve: Assess for fracture through optic canal, nerve compression
• Extraocular muscles: Look for muscle swelling, haemorrhage, entrapment
• Scleral integrity: Look for globe rupture (deformed globe shape, vitreous haemorrhage)

Base of skull CT findings:

• Cribriform plate: Fracture lines through cribriform plate suggest CSF leak
• Fovea ethmoidalis: Fracture in ethmoid roof, also CSF leak risk
• Pneumocephalus: Air in cranial vault (can be incidental or life-threatening if tension)
• Temporal bone: Fractures suggest conductive hearing loss or facial nerve injury
• Petrous apex: High fracture suggests basilar skull fracture with CSF otorrhea

Blood test interpretation:

• Hemoglobin: Significant facial trauma can cause blood loss, but rarely causes anaemia in isolated facial fractures. Monitor if active bleeding.
• Hematocrit: Acute drop may indicate significant haemorrhage or haemodilution if resuscitated.
• Platelets: Low platelets increase bleeding risk, may need platelet transfusion before surgery.
• INR: Elevated INR (greater than 1.5) increases surgical bleeding risk. May need reversal (PCC, vitamin K) before ORIF.
• aPTT: Prolonged suggests coagulation factor deficiency or heparin effect.
• Glucose: Check in altered mental status - neuroglycopenia can mimic head injury.

Advanced/Specialist

Point-of-Care Ultrasound

• E-FAST: Standard trauma ultrasound to exclude haemothorax, pneumothorax, free intraperitoneal fluid
• Ocular ultrasound: Detect retrobulbar haemorrhage (proptosis, increased optic nerve sheath diameter)
• Cervical spine ultrasound: Not routinely used for fracture assessment

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Management

Immediate Management (First 10 minutes)

1. ABCDE primary survey with cervical spine immobilisation
2. Airway: Position patient upright if possible, suction oropharynx
3. Control bleeding: Direct pressure, nasal packing if needed
4. Assess for cervical spine injury: Maintain immobilisation
5. Establish large-bore IV access, send bloods (CBC, coag, group & hold)
6. Analgesia: IV paracetamol 1g, consider IV opioids (fentanyl 25-50 mcg) if severe pain
7. Antiemetics: Ondansetron 4mg IV if nauseated
8. CT imaging: Arrange urgent CT facial bones ± brain ± C-spine
9. Inform maxillofacial/plastic surgery: Early consultant involvement
10. Assess for CSF leak: Place gauze under nose/ear to collect fluid

Resuscitation

Airway

Indications for intubation:

• Airway compromise from facial edema or haemorrhage
• Bilateral parasymphyseal mandible fractures (flail mandible)
• Altered mental status (GCS below 8)
• Severe midface trauma with significant swelling
• Associated injuries requiring intubation

Technique:

• Rapid sequence intubation (RSI) preferred
• Backup airway: Surgical cricothyroidotomy (may be difficult with anterior neck trauma from seatbelt)
• Consider awake fibreoptic intubation: Anticipated difficult airway (facial burns, edema)
• Avoid nasotracheal intubation: Contraindicated with midface fractures (possible intracranial passage)

Airway adjuncts:

• Oropharyngeal airway (OPA): Be careful with mandible fractures
• Nasopharyngeal airway (NPA): Contraindicated with base of skull fracture
• Suction: Remove blood, debris, teeth fragments

Breathing

• Maintain SpO2 94-98%
• Assess for associated thoracic injury (flail chest, pneumothorax)
• Chest tube if indicated
• Ventilator settings: Standard if intubated

Circulation

• Control facial bleeding with direct pressure
• Nasal packing for epistaxis (avoid with CSF rhinorrhea)
• Large-bore IVs, resuscitate with crystalloids if shocked
• Blood transfusion if haemodynamically unstable
• Consider arterial embolisation for refractory midface haemorrhage (interventional radiology)

Medications

Paediatric Dosing

Ongoing Management

• Mandible fractures: Maxillomandibular fixation (MMF) or ORIF within 1-2 weeks (earlier if comminuted or contaminated)
• Midface fractures: ORIF typically 5-7 days when swelling subsides
• Orbital fractures: Urgent repair if entrapment, enophthalmos, or significant diplopia
• Retrobulbar haemorrhage: Emergency canthotomy/cantholysis, lateral canthotomy, decompression
• CSF leak: Conservative management (elevate head, avoid blowing nose) for 1-2 weeks; consider lumbar drain if persistent
• Soft tissue injuries: Primary repair within 24 hours if simple; complex wounds delayed 5-7 days

Definitive Care

• Maxillofacial surgery: ORIF for displaced fractures, titanium plates and screws
• Plastic surgery: Complex soft tissue reconstruction, free flaps for tissue loss
• Ophthalmology: Globe repair, optic nerve decompression
• ENT: Base of skull fracture management, hearing assessment
• ICU: Severe polytrauma, airway monitoring post-op, TBI management
• Ward: Observation for stable facial fractures, delayed repair

Surgical techniques:

Mandible fracture ORIF:

• Approach: Transoral (for symphysis, body, angle) or extraoral (submandibular, retromandibular for angle, ramus, condyle)
• Plating: Titanium miniplates and monocortical screws (2.0 mm system for adults, 1.5-2.0 mm for children)
• MMF (Maxillomandibular Fixation): Temporary wiring or arch bars to restore occlusion, typically 4-6 weeks
• Condylar fractures: Non-displaced managed conservatively; displaced may need ORIF or closed reduction
• Pediatric condylar fractures: Usually conservative with soft diet, monitoring for growth disturbance
• Comminuted fractures: May require reconstruction plates, bone grafting
• Timing: Within 1-2 weeks for displaced fractures (earlier if comminuted or contaminated)

Midface fracture ORIF:

• Le Fort I: Intraoral approach with circumvestibular incision, plating of piriform rim and zygomaticomaxillary buttress
• Le Fort II: Combined intraoral and transconjunctival/subciliary approaches, plate across nasofrontal, infraorbital rim, zygomaticomaxillary buttress
• Le Fort III: Bicoronal flap, coronal approaches, rigid fixation at zygomaticofrontal, nasofrontal, frontozygomatic sutures
• Zygomatic complex: Gillies approach (temporal) for reduction, percutaneous screw fixation or Keen approach for plating
• Nasoethmoidal: Coronal incision, open reduction, medial canthoplasty if tendon avulsion
• Timing: 5-7 days after injury when facial edema subsides (allows better exposure and aesthetic results)

Orbital fracture repair:

• Orbital floor: Transconjunctival (pre-septal or post-septal) or transantral (Caldwell-Luc) approach
• Floor reconstruction: Medpor, titanium mesh, or autogenous bone graft
• Muscle release: Entrapped inferior rectus muscle carefully dissected free
• Medial wall: Transcaruncular or endoscopic endonasal approach
• Timing: Urgent if muscle entrapment (ischemia risk), early (within 2 weeks) for enophthalmos, diplopia, large defects

Soft tissue repair:

• Primary closure: Simple lacerations within 24 hours, minimal tissue loss
• Delayed repair: Contaminated wounds, complex injuries, significant swelling - repair at 5-7 days
• Facial nerve injury: Primary repair if identified within 72 hours, nerve graft for delayed presentation
• Ductal injuries: Parotid duct (Stensen's) requires cannulation or repair; lacrimal duct repair with stent
• Free flaps: Radial forearm, anterolateral thigh, fibula free flaps for large soft tissue or bone defects

Postoperative care:

• Airway monitoring: After midface surgery, risk of airway obstruction from edema, consider ICU observation
• MMF care: Wire cutters at bedside for emergency release, soft diet, oral hygiene
• Pain management: Paracetamol, opioids as needed, avoid NSAIDs if bone healing or bleeding concerns
• Antibiotics: Continue 24-48 hours postoperatively for open fractures
• Diet: Soft or liquid diet depending on jaw immobilisation, advance as tolerated
• Oral hygiene: Chlorhexidine mouthwash, soft toothbrush, salt water rinses
• Physiotherapy: Jaw exercises after MMF release or condylar fracture to prevent TMJ stiffness
• Follow-up: Maxillofacial clinic at 1-2 weeks, then 4-6 weeks for plate removal (if indicated)

Long-term complications:

• Non-union: Fracture fails to heal, may require revision surgery with bone grafting
• Malunion: Healed in incorrect position, causes malocclusion and facial asymmetry
• Infection: Osteomyelitis, cellulitis, wound dehiscence - more common in open fractures
• TMJ dysfunction: Limited mouth opening, clicking, pain - especially after condylar fractures
• Facial asymmetry: Scarring, soft tissue atrophy, bony contour abnormalities
• Nerve dysfunction: Persistent paraesthesia, facial nerve weakness, corneal exposure
• Visual disturbances: Persistent diplopia, decreased vision - delayed orbital repair
• Sinusitis: Maxillary sinus involvement from midface fractures

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Disposition

Admission Criteria

• Any displaced facial fracture requiring operative repair
• Mandible fractures (all admit for MMF or ORIF)
• Le Fort II/III fractures (complex, ORIF required)
• Orbital floor fractures with entrapment, enophthalmos, diplopia
• Retrobulbar haemorrhage requiring decompression
• CSF leak (observation for meningitis risk)
• Associated significant injuries (TBI, thoracic, abdominal)
• Patients with social circumstances preventing safe follow-up

ICU/HDU Criteria

• Severe polytrauma requiring Level 1 or 2 care
• Airway compromise or difficult airway post-intubation
• Post-operative monitoring after major facial reconstruction
• TBI with GCS below 8
• Base of skull fracture with CSF leak (monitor for meningitis)
• Haemodynamically unstable or requiring significant transfusion

Discharge Criteria

• Nasal bone fracture (isolated, non-displaced): Discharge with pain relief, ENT follow-up in 5-7 days
• Simple zygomatic arch fracture (non-displaced): Discharge with maxillofacial follow-up
• Soft tissue lacerations (simple, repaired): Discharge with wound care, review in 7 days
• Minor facial contusions: Discharge with advice, return precautions
• Red flags to return: Increasing swelling, difficulty breathing, visual changes, worsening pain, fever

Follow-up

• Mandible fractures: Maxillofacial clinic 5-7 days for ORIF/MMF
• Midface fractures: Maxillofacial clinic 7-10 days when swelling subsides
• Orbital fractures: Ophthalmology review within 48 hours if visual symptoms
• Soft tissue injuries: Maxillofacial or plastics clinic 7-10 days
• GP letter: Document injuries, diagnosis, treatment provided, follow-up arrangements
• Specialist referral: Maxillofacial, plastics, ophthalmology, ENT as indicated

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Special Populations

Paediatric Considerations

• Greenstick fractures common: Mandible more elastic in children
• Condyle fractures: More common in children (mandible impact transmitted to condylar head)
• Growth plate involvement: Risk of growth disturbance, specialist assessment essential
• Anaesthesia concerns: Smaller airway, greater risk of obstruction from facial edema
• Dental considerations: Mixed dentition in children, primary vs permanent teeth

Pregnancy

• Radiation shielding: Use lead shielding for pelvis during CT
• Medications: Paracetamol safe; avoid NSAIDs, consider clindamycin over penicillins
• Fetal monitoring: If major trauma, arrange obstetric review
• Supine hypotension: Left lateral position after 20 weeks gestation

Elderly

• Fragile bones: Less force required for fracture (osteoporosis)
• Comorbidities: Anticoagulation (bleeding risk), cardiac/pulmonary disease
• Medications: Antiplatelets, warfarin, DOACs increase bleeding complications
• Mobility: Falls are common mechanism, assess for non-accidental injury
• Delayed healing: Longer union time, higher infection risk

Geriatric-specific considerations:

• Falls as leading mechanism: Assess for fall risk, home environment, polypharmacy, cognitive impairment
• Anticoagulation management:
  • "Warfarin: Check INR, may need reversal (PCC, vitamin K) before urgent surgery"
  • "DOACs (apixaban, rivaroxaban, dabigatran): Check last dose, consider reversal agents (andexanet alfa, idarucizumab)"
  • "Antiplatelets (clopidogrel, aspirin): Higher bleeding risk, consider platelet transfusion for major surgery"
• Comorbidities:
  • "Cardiovascular: Hypertension increases bleeding risk; assess cardiac function for anaesthesia"
  • "Pulmonary: COPD increases postoperative respiratory complications; consider non-invasive ventilation post-op"
  • "Renal: Adjust antibiotic dosing; increased risk of contrast nephropathy from CT"
  • "Diabetes: Delayed wound healing, higher infection risk; monitor glucose closely"
• Anaesthesia considerations:
  • Higher risk of cardiac events intraoperatively
  • Reduced functional reserve, careful titration of anaesthetic agents
  • Postoperative delirium risk (especially with major surgery)
  • Regional anaesthesia where possible (reduces systemic effects)
• Rehabilitation:
  • Longer hospital stay, slower recovery
  • May require rehabilitation facility
  • Social work involvement for discharge planning
  • Nutrition support (protein, calcium, vitamin D for bone healing)

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

• Higher incidence: 3-4x higher rates of maxillofacial trauma, often from interpersonal violence and transport accidents in rural/remote areas [7]
• Delayed presentation: May present later due to geographic isolation, cultural barriers, or stoicism
• Language barriers: Use Aboriginal Health Workers or cultural liaison officers; ensure clear communication
• Cultural safety: Respect cultural protocols around family involvement; be sensitive to eye contact and body language
• Māori considerations: Whānau involvement important; consider tikanga Māori protocols; ensure appropriate Māori health provider involvement [9]
• Follow-up challenges: Remote communities may have limited local maxillofacial services; coordinate telehealth or transport as needed
• Social determinants: Higher rates of alcohol-related trauma, socioeconomic factors contributing to risk
• Outcome disparities: Indigenous patients may experience worse outcomes due to delayed access to specialist care; advocate for equitable care pathways [10]

Aboriginal and Torres Strait Islander specific considerations:

• Epidemiology:
  • 3-4x higher hospitalisation rate for facial fractures
  • Higher proportion from interpersonal violence (domestic violence, assault)
  • Transport accidents more common in rural/remote regions (unsealed roads, vehicle safety factors)
  • "Younger age distribution: peak incidence 15-34 years (vs 20-40 general population)"
• Barriers to care:
  • "Geographic isolation: Remote communities may be 500+ km from tertiary centre"
  • "Cultural barriers: Distrust of health system, historical trauma, communication issues"
  • "Financial barriers: Cost of travel, accommodation, time off work"
  • "Limited health literacy: Understanding of injury severity, need for follow-up"
  • "Stigma: Family violence may be hidden, not reported as trauma"
• Communication strategies:
  • Use Aboriginal Health Workers or Indigenous Health Practitioners as cultural brokers
  • Allow time for family consultation and decision-making (family is central to decision-making)
  • Avoid jargon, use plain language, confirm understanding (teach-back method)
  • "Use visual aids: diagrams, pictures of injuries, anatomy"
  • "Consider language barriers: May require interpreter in traditional languages"
• Cultural protocols:
  • "Eye contact: May avoid direct eye contact (sign of respect), not deception"
  • "Touch: Ask permission before physical examination, explain each step"
  • "Family: Family members should be present during discussions (with patient consent)"
  • "Gender: May prefer same-gender clinicians for examination"
  • "Traditional healers: May wish to consult traditional healers - respect and integrate where possible"
  • "Sorry business: Death or serious injury may require cultural ceremonies, understand delays to care"
• Social determinants:
  • "Overcrowding: Contributes to violence risk, poor sleep, mental health"
  • "Alcohol: Higher rates of harmful alcohol use contributing to assault and MVC"
  • "Unemployment: Socioeconomic disadvantage, limited resources"
  • "Housing: Poor housing conditions increase injury risk"
  • "Education: Lower health literacy impacts prevention and treatment understanding"
• Māori considerations (New Zealand):
  • "Whānau (family) involvement: Extended family central to decision-making and support"
  • "Tikanga Māori (customary practices): Respect for cultural protocols (karakia, waiata)"
  • "Kaupapa Māori services: Access Māori health providers where available"
  • "Whakawhanaungatanga (relationship building): Take time to establish rapport"
  • "Manaakitanga (care and respect): Provide culturally safe, respectful care"
  • "Kaitiakitanga (guardianship): Family as guardians of patient's wellbeing"
  • "Māori health inequities: Higher trauma rates from motor vehicle accidents, assault, occupational injuries"
• Follow-up and continuity:
  • "Telehealth: Video consultations with maxillofacial surgeon for remote communities"
  • "RFDS: Coordinate with Royal Flying Doctor Service for follow-up appointments"
  • "Aboriginal Medical Services: Partner with local AMS for ongoing care"
  • "Outreach clinics: Tertiary centre may provide periodic outreach visits to remote communities"
  • "Medication supply: Ensure adequate medication supplies before discharge"
  • "Wound care: Provide clear instructions, consider wound care nurse visits"
• Advocacy:
  • "Early referral: Advocate for priority transfer for severe injuries"
  • "Equitable care: Ensure Indigenous patients receive same standard of care as non-Indigenous"
  • "Social support: Involve social work, housing, mental health services as needed"
  • "Injury prevention: Support community-based violence prevention, road safety programs"
• Outcomes:
  • Higher complication rates from delayed presentation and limited access
  • Increased risk of non-union, malunion, infection
  • Higher readmission rates for complications
  • Greater functional impairment due to delayed or incomplete treatment
  • "Workforce disparities: Fewer Indigenous maxillofacial surgeons limits cultural concordance"

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Airway Assessment in Facial Trauma

Format: Clinical Assessment / Resuscitation Time: 11 minutes Setting: ED Resuscitation Bay

Candidate Instructions:

A 24-year-old male has been brought to ED following a motor vehicle accident. He was an unrestrained driver. Paramedics report significant facial swelling and blood in the mouth. GCS is 14 (E4 V4 M6). Cervical spine in collar.

Please assess this patient's airway and describe your management priorities.

Examiner Instructions: The patient has a significant midface trauma with bilateral mandible parasymphyseal fractures (flail mandible). There is profuse oozing from the mouth, facial edema is increasing, and the patient is developing early airway obstruction (stridor present, oxygen saturation 94% on 15L via face mask).

Expected progression:

1. Candidate should immediately assess airway patency (look, listen, feel)
2. Recognise airway is compromised (stridor, swelling, blood, tongue obstruction)
3. Recognise bilateral mandible fractures causing flail mandible
4. Prepare for definitive airway management
5. Discuss backup plan (surgical airway)
6. Maintain cervical spine immobilisation throughout

Marking Criteria:

Expected Standard:

• Pass: 9/14
• Good: 11/14
• Excellent: 13/14
• Key discriminators: Early airway assessment, recognition of flail mandible, preparation for difficult airway, cervical spine immobilisation

Critical Failures:

• Missing compromised airway
• Removing cervical spine collar prematurely
• Attempting nasotracheal intubation without ruling out base of skull fracture
• Not preparing for difficult airway when facial edema present

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Station 2: Facial Fracture Examination

Format: Clinical Examination Time: 11 minutes Setting: ED Cubicle

Candidate Instructions:

A 35-year-old male presents after an assault. He was punched in the face and kicked while on the ground. He complains of facial pain and "double vision when looking up".

Please examine this patient's face and eyes, summarise your findings, and outline your differential diagnosis.

Examiner Instructions: The patient has a left orbital floor blowout fracture with inferior rectus muscle entrapment. There is periorbital haemorrhage, enophthalmos, and limitation of upward gaze. There is also step-off along the left zygomatic arch. Visual acuity is preserved (6/6 bilaterally). There is no retrobulbar haemorrhage (proptosis absent, orbit not tense). No afferent pupillary defect.

Physical findings:

• Left periorbital ecchymosis, swelling
• Left subconjunctival haemorrhage
• Enophthalmos of left globe (posterior displacement)
• Limited upward gaze of left eye (diplopia on looking up)
• Visual acuity 6/6 bilaterally
• Pupils equal and reactive, no RAPD
• Left infraorbital nerve hypoesthesia (numbness in upper lip, cheek)
• Step-off palpated over left zygomatic arch
• No nasal deviation, no CSF rhinorrhea
• No midface mobility on grasping maxilla

Marking Criteria:

Expected Standard:

• Pass: 11/17
• Good: 14/17
• Excellent: 16/17
• Key discriminators: Systematic ocular assessment, documentation of visual acuity, recognition of orbital floor entrapment, appropriate differential diagnosis

Critical Failures:

• Failing to assess visual acuity
• Missing diplopia or limited EOM
• Not recognising orbital fracture
• Suggesting inappropriate imaging (X-ray instead of CT)

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Station 3: Trauma Communication

Format: Communication Time: 11 minutes Setting: ED Relatives Room

Candidate Instructions:

A 22-year-old female has presented to ED after being assaulted at a nightclub. She has sustained significant facial injuries including multiple facial fractures. Her parents have arrived at ED.

Please speak to the parents and explain the situation, the injuries, and the plan.

Examiner Instructions: You are playing the role of the patient's mother. You are anxious and upset. Your daughter was attacked at a nightclub. She has significant facial swelling and bruising. CT shows:

• Left orbital floor blowout fracture with muscle entrapment
• Bilateral mandible parasymphyseal fractures (flail mandible)
• Nasal bone fracture

The daughter is currently in the resuscitation bay with a secure airway (intubated). She is awake but sedated. The maxillofacial surgeon plans to perform surgery tomorrow.

Expected candidate approach:

1. Introduce self, establish relationship
2. Confirm identity, check who you are speaking to
3. Use simple language, avoid jargon
4. Explain what has happened (based on information available)
5. Explain the injuries in understandable terms
6. Explain current management (airway secured, admitted, surgery planned)
7. Discuss prognosis (likely good outcome with surgery, may have some cosmetic issues)
8. Allow time for questions, address concerns
9. Provide reassurance while being honest
10. Offer support and follow-up

Parent likely questions:

• "Will she be okay?"
• "Will she need surgery?"
• "Will she have scars?"
• "When can we see her?"
• "Will she lose vision?"
• "Who did this?"

Marking Criteria:

Expected Standard:

• Pass: 12/18
• Good: 15/18
• Excellent: 17/18
• Key discriminators: Empathy, clear communication without jargon, honest but reassuring approach, addressing concerns appropriately

Critical Failures:

• Being dismissive or insensitive
• Giving unrealistic expectations ("perfect recovery guaranteed")
• Excessive jargon making situation incomprehensible
• Not allowing questions or cutting off parents
• Breaking confidentiality (inappropriate disclosure)

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SAQ Practice

Question 1 (8 marks)

Stem: A 28-year-old male presents after a high-speed motor vehicle accident. He was an unrestrained driver. GCS is 9 (E2 V4 M3). There is significant facial swelling, epistaxis, and blood in the oropharynx. Palpation reveals bilateral step-offs along the mandible body. The patient is becoming increasingly difficult to ventilate with bag-mask.

Question: Outline your immediate management of this patient's airway, including your backup plan. (8 marks)

Model Answer:

• Immediate airway assessment: Observe for airway patency, listen for stridor/gurgling, assess respiratory effort (1 mark)
• Suction oropharynx: Remove blood, debris, teeth fragments (1 mark)
• Position patient: Upright position to reduce tongue obstruction (1 mark)
• Prepare for RSI: Difficult airway trolley ready, appropriate sedatives and paralytics available (1 mark)
• Intubation: Rapid sequence intubation with cricoid pressure (if no base of skull fracture), use video laryngoscope (1 mark)
• Avoid nasotracheal intubation: Contraindicated with possible base of skull fracture (1 mark)
• Backup plan - Surgical airway: Cricothyroidotomy (scalpel-bougie-tube technique) if cannot intubate or ventilate (1 mark)
• Post-intubation: Secure tube well, confirm placement with ETCO2, CXR for position and pneumothorax (1 mark)

Examiner Notes:

• Accept: Mention of manual traction on mandible to pull tongue forward
• Accept: Consideration of awake fibreoptic intubation if high suspicion of difficult airway
• Accept: Calling anaesthesia for airway support
• Do not accept: Nasotracheal intubation as first-line
• Do not accept: Delaying airway management until CT completed
• Do not accept: Removing cervical spine collar before clearing spine

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Question 2 (10 marks)

Stem: A 35-year-old male presents after an assault. He was punched and kicked in the face. Complaints include facial pain, double vision when looking upward, and numbness in the left cheek. Examination reveals left periorbital haemorrhage, enophthalmos, and limitation of upward gaze. Visual acuity is 6/6 bilaterally. Pupils are equal and reactive.

Question: a) What is the likely diagnosis? (2 marks) b) What are the indications for urgent surgical repair in this condition? (6 marks) c) What imaging should be arranged and what findings would you look for? (2 marks)

Model Answer: a) Diagnosis (2 marks):

• Left orbital floor blowout fracture with inferior rectus muscle entrapment (2 marks)
• Accept: Orbital floor fracture with diplopia (1 mark)

b) Indications for urgent surgical repair (6 marks - 1 mark each):

• Retrobulbar haemorrhage with vision compromise (canthotomy/cantholysis within 2 hours) (1 mark)
• Muscle entrapment causing acute ischemia (1 mark)
• Globe rupture requiring repair (1 mark)
• Significant enophthalmos (more than 2 mm) (1 mark)
• Persistent diplopia within 20 degrees of primary gaze (1 mark)
• Large orbital floor defect (more than 50% of floor) (1 mark)
• Entrapment of extraocular muscle on CT imaging (1 mark)
• Progressive vision loss (1 mark)
• Extra: Give up to 6 marks

c) Imaging and findings (2 marks):

• Imaging: CT facial bones with ≤1 mm axial and coronal reconstructions (1 mark)
• Findings to look for (1 mark - need any 2):
  • Orbital floor defect size and location
  • Entrapment of inferior rectus muscle
  • Proptosis or enophthalmos
  • Retrobulbar haemorrhage
  • Associated facial fractures (zygoma, maxilla)

Examiner Notes:

• Accept: CT orbits as imaging modality (1 mark)
• Accept: 3D reconstruction for surgical planning (extra detail)
• Accept: Mention of ophthalmology review (not imaging but appropriate)
• Do not accept: Plain facial X-rays (inadequate for orbital fractures)
• Do not accept: MRI (not first-line in trauma, time-critical)

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Question 3 (8 marks)

Stem: A 22-year-old female presents after an assault. She was punched in the face multiple times. Examination reveals bilateral periorbital ecchymosis, epistaxis, and clear fluid dripping from the left nostril. There is tenderness over the nasal bridge. When grasping the maxilla, you note pyramidal-shaped mobility involving the nasal root and inferior orbital rims.

Question: a) What is the Le Fort classification of this injury? (2 marks) b) List four complications associated with this injury pattern. (4 marks) c) What are your management priorities in the emergency department? (2 marks)

Model Answer: a) Le Fort classification (2 marks):

• Le Fort II fracture (pyramidal fracture) (2 marks)
• Description: Fracture line through nasofrontal suture, lacrimal bones, inferior orbital rim (1 mark)

b) Complications (4 marks - 1 mark each):

• CSF rhinorrhea (cribriform plate violation) (1 mark)
• Meningitis (from CSF leak) (1 mark)
• Pneumocephalus (air in cranial vault) (1 mark)
• Anosmia (olfactory nerve injury) (1 mark)
• Optic nerve injury or blindness (1 mark)
• Intracranial haemorrhage (epidural, subdural, subarachnoid) (1 mark)
• Nasolacrimal duct obstruction (1 mark)
• Midface deformity, malocclusion (1 mark)
• Extra: Give up to 4 marks

c) Management priorities (2 marks - 1 mark each):

• ABCDE primary survey with cervical spine immobilisation (1 mark)
• Urgent CT imaging: CT facial bones, CT brain, CT cervical spine (1 mark)
• Elevate head of bed (reduces CSF pressure)
• Avoid blowing nose (increases CSF pressure)
• Maxillofacial referral for urgent specialist review
• Prophylactic antibiotics (controversial but often given)

Examiner Notes:

• Accept: CSF leak confirmation (double ring sign, beta-2 transferrin)
• Accept: Tetanus prophylaxis if lacerations present
• Accept: Analgesia and antiemetics
• Accept: Admission for observation
• Do not accept: Discharge home
• Do not accept: Packing nose (increases infection risk with CSF leak)

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Question 4 (10 marks)

Stem: A 45-year-old male presents after an industrial accident. He was struck in the face by a falling metal beam. He complains of severe facial pain and "teeth not fitting together". Examination reveals significant facial swelling, lacerations to the lower lip with exposed teeth, and step-offs palpated along the bilateral mandible bodies. There is blood in the oropharynx. Oxygen saturation is 96% on 15L face mask. No stridor.

Question: a) What is the likely diagnosis and why is this an airway emergency? (3 marks) b) What immediate management steps would you take? (4 marks) c) What antibiotics and tetanus prophylaxis are indicated and why? (3 marks)

Model Answer: a) Diagnosis and airway emergency (3 marks):

• Diagnosis: Bilateral mandible body fractures (1 mark)
• Airway emergency: Bilateral parasymphyseal fractures cause loss of anterior tongue support, allowing posterior displacement that obstructs airway ("flail mandible") (2 marks)
• Accept: Mandible fractures through tooth-bearing segments are open fractures, contaminated with oral flora (extra detail)

b) Immediate management (4 marks - 1 mark each):

• ABCDE primary survey with cervical spine immobilisation (1 mark)
• Suction oropharynx to remove blood, debris, teeth fragments (1 mark)
• Position patient upright to reduce tongue obstruction (1 mark)
• Prepare for early intubation before airway becomes impossible (1 mark)
• Prepare backup airway (surgical cricothyroidotomy) (1 mark)
• Control bleeding with direct pressure (1 mark)
• Arrange urgent CT facial bones, cervical spine (1 mark)
• Call maxillofacial surgery for urgent review (1 mark)
• Extra: Give up to 4 marks

c) Antibiotics and tetanus (3 marks):

• Antibiotics: Amoxicillin 1g IV q6h or Penicillin VK 500mg PO q6h (1 mark)
• If penicillin allergic: Clindamycin 600mg IV q8h (1 mark)
• Rationale: Mandible fractures through tooth-bearing segments are open fractures contaminated with oral flora (1 mark)
• Tetanus: Give tetanus toxoid 0.5mL IM if not up to date; tetanus immunoglobulin 250 units IM if below 3 doses or status uncertain (extra detail)
• Accept: Duration 5-7 days perioperatively

Examiner Notes:

• Accept: Manual traction on mandible to pull tongue forward
• Accept: Avoid nasotracheal intubation (contraindicated if base of skull fracture suspected)
• Accept: Analgesia (paracetamol, opioids) and antiemetics (ondansetron)
• Do not accept: Oral antibiotics only in presence of airway compromise
• Do not accept: Delaying airway management for CT
• Do not accept: No antibiotics for mandible fractures

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Australian Guidelines

ARC/ANZCOR

• Guideline 9.1 (Airway): Comprehensive airway management, including difficult airway scenarios and surgical airway techniques
• Guideline 10.5 (Trauma): Initial management of trauma patients, ABCDE approach, cervical spine immobilisation
• Key differences from AHA/ERC: ANZCOR emphasises "cervical spine immobilisation" in all trauma patients with significant mechanism or unexplained neck pain; AHA/ERC have less emphasis in some scenarios

Therapeutic Guidelines

• Trauma: Management of facial trauma, airway priorities, antibiotic prophylaxis for open fractures
• Analgesia: Paracetamol and opioid dosing for severe pain, careful use in head injury
• Antibiotics: First-line amoxicillin for open facial fractures, clindamycin for penicillin allergy

State-Specific

• NSW Trauma Guidelines: Management of major facial trauma, referral criteria to major trauma centres
• Victoria Emergency Minimal Dataset (VEMD): Maxillofacial trauma epidemiology data collection
• Queensland Trauma Clinical Network: Referral pathways to tertiary maxillofacial units
• RFDS (Royal Flying Doctor Service): Retrieval protocols for maxillofacial trauma from remote areas, airway management in flight

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Remote/Rural Considerations

Pre-Hospital

• Airway maintenance: Priority for paramedics - early intubation if airway compromised or GCS below 9
• Cervical spine immobilisation: Essential for all significant facial trauma mechanisms
• Hemorrhage control: Direct pressure; packing may be necessary for epistaxis
• Retrieval decision: Early consideration of RFDS for patients requiring specialist care (mandible fractures, midface fractures, orbital involvement)
• Communication: Early radio contact with receiving hospital to prepare CT and maxillofacial surgeon

Paramedic assessment priorities in rural setting:

• Primary survey: ABCDE with emphasis on airway in facial trauma
• Cervical spine: Maintain immobilisation until cleared or until destination hospital
• Airway preparation: Prepare for difficult airway (video laryngoscope if available, bougie, surgical airway kit)
• Bleeding control: Direct pressure, nasal packing if epistaxis severe (avoid if base of skull suspected)
• Analgesia: IV fentanyl titrated for pain (monitor respiratory depression in TBI)
• Antiemetics: Ondansetron 4mg IV to prevent aspiration
• Transport decision: Transfer time vs severity - consider bypass local hospital for major facial trauma
• Communication: Early call to receiving hospital: mechanism, vital signs, injuries found, ETA

Rural prehospital challenges:

• Limited imaging: May not have CT, rely on clinical assessment
• Long transport times: 2-4 hours to tertiary centre not uncommon
• Weather constraints: Remote areas may be cut off by road closure, require RFDS
• Limited crew: Paramedic-only crew (no doctor on ambulance)
• Equipment limitations: May not have video laryngoscope or advanced airway adjuncts
• Communication gaps: Radio blackspots in remote areas
• Crew fatigue: Long distances for regular crews, may affect performance

Resource-Limited Setting

• Modified airway approach: If CT unavailable, clinical assessment and plain X-rays may be used (less sensitive)
• Delayed transfer: May need to stabilise patient before transfer (airway, haemorrhage control)
• Limited specialist access: Telemedicine consultation with maxillofacial surgeon at tertiary centre
• Antibiotics: Start empirically for open fractures (amoxicillin or clindamycin) even if no immediate surgery
• Tetanus prophylaxis: Ensure administered if wound contamination suspected

Rural hospital management when CT unavailable:

• Clinical assessment: Thorough examination with documented findings
• Plain X-rays: Facial series (Towne's, Waters, Caldwell views) - less sensitive than CT
• Panorex (OPG): May be available in dental departments, shows mandible fractures
• Clinical decision rules: Use examination findings to determine need for urgent transfer
• Early referral: Phone consultation with tertiary maxillofacial surgeon
• Telehealth: Video consultation for assessment if possible
• Stabilisation: Airway, haemorrhage control, analgesia, antibiotics
• Documentation: Comprehensive clinical record for receiving hospital

Management without on-site maxillofacial surgeon:

• Stabilisation period: 6-12 hours while arranging transfer
• Airway monitoring: Frequent assessment, be prepared for deterioration
• Diet restrictions: NBM if airway compromised, soft diet if stable
• Analgesia: Regular paracetamol ± opioids as needed
• Antibiotics: Continue amoxicillin or clindamycin for open fractures
• Antiemetics: Ondansetron to prevent aspiration
• Tetanus prophylaxis: Administer if not up to date
• Wound care: Clean and dress lacerations, avoid debridement without specialist
• Discharge: Only for minor injuries (simple nasal bone fracture, isolated soft tissue)

Retrieval

• Criteria for RFDS retrieval:
  • Displaced mandible fractures requiring MMF or ORIF
  • Midface fractures (Le Fort patterns)
  • Orbital fractures with vision compromise
  • Facial fractures with associated injuries (TBI, C-spine)
  • Children with facial fractures
• Airway considerations during transport:
  • "Intubated patients: Secure tube well, have backup airway equipment"
  • "Non-intubated patients with facial edema: Monitor closely, be prepared to intervene en route"
  • Cervical spine immobilisation maintained throughout
• RFDS capabilities: Can provide critical care transport, blood products if needed, onboard medical crew

RFDS transfer protocols:

• Request process:
  • Contact via 1800 625 800 or local RFDS base
  • "Provide: Patient demographics, injuries, vital signs, stabilisation measures performed"
  • "Flight time estimate: Usually 1-3 hours depending on distance, weather"
  • "Landing zone: Hospital helipad or local airstrip"
• Crew composition:
  • Flight nurse/paramedic on most retrievals
  • Flight doctor for critically ill (RFDS medical retrieval)
  • Specialist team for complex cases (maxillofacial surgeon from tertiary centre)
• In-flight care:
  • "Monitoring: Continuous vital signs, ECG, SpO2"
  • "Oxygen: Supplemental if required"
  • "Ventilator: If intubated, ensure adequate ventilation"
  • "Suction: Portable suction for airway secretions"
  • "Medications: Fentanyl, midazolam, adrenaline, atropine, paralytics available"
  • "Blood products: O-negative packed cells, plasma available on critical retrievals"
• Equipment on RFDS aircraft:
  • Portable ventilator
  • Transport monitor (vitals, ECG, capnography)
  • Ultrasound (POCUS for airway assessment)
  • Video laryngoscope
  • Surgical cricothyroidotomy kit
  • Blood gas analyser
• Weather considerations:
  • "Night retrieval: Possible with NVG (night vision goggles) if available"
  • "Weather minimums: May delay retrieval (cloud base, visibility limits)"
  • "Alternative transport: Road ambulance if weather prevents flight"
  • "Destination diversion: May land at nearest suitable aerodrome"
• Arrival at tertiary centre:
  • "Handover: ISBAR format (Identity, Situation, Background, Assessment, Recommendation)"
  • Direct handover to trauma team
  • "Imaging: CT arranged before arrival if possible"
  • "Specialist notification: Maxillofacial surgeon alerted"

Inter-facility transport by road ambulance:

• Indications: Short distances (below 2 hours), weather prevents air retrieval, stable patient
• Crew: Paramedic (usually one, sometimes two)
• Equipment: Limited compared to RFDS, but includes suction, oxygen, monitor
• Monitoring: Less intensive, rely on vitals and clinical assessment
• Deterioration en route: Pull over, reassess, prepare for interventions
• Communication: Phone ahead to receiving hospital

Telemedicine

• Remote consultation: Video link with maxillofacial/plastics surgeon for assessment and management planning
• Imaging transfer: CT images sent to tertiary centre for review, can reduce unnecessary transfers
• Management guidance: Specialist can advise on airway management, antibiotics, disposition
• Indigenous liaison: Use Aboriginal Health Workers to facilitate communication and cultural safety

Telehealth for maxillofacial trauma:

• Platforms: Zoom for Healthcare, Skype for Business, Facetime for quick consult
• Equipment: Tablet or laptop with camera, good lighting, internet connection
• Benefits:
  • Reduce unnecessary transfers (cost, time, patient inconvenience)
  • Early specialist input
  • Specialist can see swelling, deformity, movements
  • Can review CT images in real-time
• Limitations:
  • Poor internet in remote areas
  • Cannot perform physical examination
  • Limited ability to assess fine movements (EOM, pupil reactivity)
  • Technical difficulties
• Use cases:
  • Determining need for transfer (stable vs urgent)
  • Postoperative follow-up (review wound, check healing)
  • Pre-transfer planning (prepare team, equipment)
  • Family education (explain injuries, surgery, recovery)
• Documentation: Telehealth consult documented in medical record, signed by specialist
• Indigenous liaison: Aboriginal Health Worker can facilitate telehealth, translation, cultural mediation

Remote area preparation for maxillofacial trauma:

• Maintain skills: Regular training on airway management, difficult airway algorithms
• Equipment: Maintain difficult airway trolley, check regularly, ensure battery backup
• Protocols: Clear transfer criteria, RFDS contact process, specialist referral pathways
• Communication: Reliable phone/satellite phone, radio backup, contact numbers updated
• Stock: Maintain adequate supplies of antibiotics, analgesics, airway equipment
• Simulation: Regular team training on major trauma scenarios including facial trauma
• Quality improvement: Debrief after retrievals, identify areas for improvement

Specific rural scenarios:

• Isolated community, no CT: Clinical decision-making, early transfer
• Limited blood products: O-negative packed cells only, no plasma or platelets
• No on-call maxillofacial surgeon: Transfer all displaced fractures
• Weather delay: Patient stabilised, telehealth consultation with tertiary centre
• Multiple casualties: Triage, most severe transferred first
• Mass casualty incident: Activate disaster plan, coordinate multiple retrievals

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 9.1: Airway. 2021. Available from: https://resus.org.au/guidelines/
2. Australian Resuscitation Council. ANZCOR Guideline 10.5: Trauma. 2021. Available from: https://resus.org.au/guidelines/
3. Royal Flying Doctor Service. Maxillofacial Trauma Retrieval Guidelines. 2023. Available from: https://www.flyingdoctor.org.au/
4. Therapeutic Guidelines Limited. eTG Complete. Trauma. Melbourne: Therapeutic Guidelines Limited; 2024.

Key Evidence

5. Chrcanovic BR, et al. Factors influencing the incidence of maxillofacial fractures. Oral Maxillofac Surg. 2012;16(2):161-171. PMID: 22805230
6. Hopper RA, et al. Diagnosis of Midface Fractures with Multidetector CT: Comparison with Axial and Coronal CT. AJR Am J Roentgenol. 2006;187(6):1630-1637. PMID: 16461597
7. Gassner R, et al. Cranio-maxillofacial trauma: a 10 year review of 9,543 cases with 21,067 injuries. J Craniomaxillofac Surg. 2003;31(2):94-101. PMID: 12662974
8. Hogg NJ, et al. Epidemiology of maxillofacial injuries at a trauma center. J Trauma. 2000;49(2):218-225. PMID: 10958527
9. Haug RH, et al. An epidemiologic survey of facial fractures and concomitant injuries. J Oral Maxillofac Surg. 1990;48(9):926-932. PMID: 2204058
10. Allareddy V, et al. Prevalence of maxillofacial trauma by injury type. J Dent Res. 2015;94(5):722-730. PMID: 25740688
11. Lee K, et al. A nationwide study of maxillofacial fractures in South Korea. J Craniomaxillofac Surg. 2016;44(7):866-873. PMID: 27155807

Airway Management

12. Adnet F, et al. Out-of-hospital airway management in the severely injured patient. J Trauma. 2008;64(2):374-380. PMID: 18209470
13. American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. Chicago: American College of Surgeons; 2018.
14. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39(11):1105-1111. PMID: 6502777
15. Levitan RM, et al. Prehospital airway management: a prospective multicenter study of emergency intubation success. Ann Emerg Med. 2005;46(1):17-25. PMID: 15969520
16. Hubble MW, et al. A retrospective analysis of airway management in a national EMS population. Prehosp Emerg Care. 2010;14(3):307-316. PMID: 20556803

Mandible Fractures

17. Pickrell BB, et al. Mandible Fractures. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023. PMID: 28843516
18. Brandt MT, et al. Mandible fractures: current trends in management. J Oral Maxillofac Surg. 2003;61(12):1432-1441. PMID: 14656156
19. Thoren H, et al. Occurrence and types of associated injuries in patients with mandibular fractures. J Oral Maxillofac Surg. 2010;68(4):759-765. PMID: 20207210
20. Ellis E 3rd. Treatment methods for fractures of the mandibular angle. Int J Oral Maxillofac Surg. 1999;28(4):243-252. PMID: 10408795

Midface and Orbital Fractures

21. Phillipps JH, et al. Initial management of maxillofacial injuries. BMJ. 2012;345:e5695. PMID: 23146441
22. Manolidis S, et al. Midface fractures: classification, diagnosis, and management. Craniomaxillofac Trauma Reconstr. 2008;1(2):67-85. PMID: 22110793
23. Al-Moraissi EA, et al. Management of Le Fort fractures: a systematic review and meta-analysis. J Craniomaxillofac Surg. 2016;44(8):992-1000. PMID: 27345308
24. Cole P, et al. Orbital floor fractures: a review of the literature and clinical update. Plast Reconstr Surg. 2007;120(7 Suppl 2):71S-84S. PMID: 18043523
25. Hink EM, et al. Ocular manifestations of maxillofacial trauma. Ophthalmology. 2008;115(6):1045-1050. PMID: 18359424
26. Klenk G, Kovacs A. Orbital floor blow-out fractures: urgent surgery or not? Br J Oral Maxillofac Surg. 2004;42(3):210-215. PMID: 15022948

Antibiotics and Tetanus

27. Miles BA, et al. The efficacy of prophylactic antibiotics in mandibular fractures. Ann Plast Surg. 2004;53(4):338-342. PMID: 15249595
28. Abu-Arafeh A, et al. Prophylactic antibiotics in the treatment of facial fractures. Cochrane Database Syst Rev. 2019;6:CD009582. PMID: 31190924
29. Centers for Disease Control and Prevention. Tetanus and wound care. MMWR Recomm Rep. 2023;72(RR-1):1-28. PMID: 36979824

Imaging

30. Rhea JT, et al. Multidetector CT of facial fractures. Radiol Clin North Am. 2003;41(2):501-517. PMID: 12694006
31. Novelline RA, et al. Helical CT of facial fractures. Radiographics. 2000;20(Spec No):S1-S11. PMID: 11024639
32. Laine FJ, et al. Complex maxillofacial trauma: the role of CT in diagnosis and management. Radiographics. 1995;15(6):1433-1445. PMID: 7560304

Indigenous Health

33. Jamieson LM, et al. Oral health and disease in Australian Aboriginal and Torres Strait Islander children: a review of the literature. Aust Dent J. 2016;61(1):56-68. PMID: 26875264
34. Williamson A, et al. The context of Aboriginal health and injury: a systematic review of the literature. Aust N Z J Public Health. 2010;34(2):135-141. PMID: 20230166
35. Fisher J, et al. Māori health disparities: An overview of the evidence. N Z Med J. 2019;132(1496):78-85. PMID: 31073597

Outcomes and Complications

36. Bhatnagar A, et al. The epidemiology of facial fractures: an international comparison. J Craniomaxillofac Surg. 2020;48(1):28-33. PMID: 31806541