Local anesthesia in facial and jaw fractures

Local

Anesthesia RICHARD M.

HERD,

D.D.S.

in Facial

and Jaw Fractures

AND JOHN C. WEETER,

tbe Department of Surgery, Louisde General Rospitcd, University of Louisvilte Scboo! of Medicine, Louisville, Ky.

From

M.D., Louisville,

Kentucky

utilize regiona or infiltration anesthesia and perform the procedures at the bedside. The most important first step in the examination and treatment of jaw and facial. fractures is the obtaining of adequate x-ray fi1m.s. In many cases stereoscopic fiIms are preferabIe in order to ascertain the exact reIationship of the fragments. One of the first things ordinarily done whiIe waiting for deveIopment of the firms is the administration of tetanus antitoxin or an active immunization with tetanus toxoid. Graham and Scott2 have shown that active immunization with toxoid reduces the incidence of tetanus if the patient has aIready been activeIy immunized. We then use a “booster” dose of I cc. If the patient has not been activeIy immunized, 1,500 American units of antitoxin should be given and repeated at weekly intervaIs until three doses have been administered.

IN the surgicaI treatment of faciaI or jaw injuries the anesthesia of choice is of great importance, This paper iIIustrates the use of 2-isobuty1 amino ethy1 meta amino benzoate (unacainea) in sixty-three facia1 and mandibuIar fractures and other frequently encountered facia1 injuries, with specia1 reference to cerebra1 injury as a compIicating factor.

HEAD INJURIES WITH POSSIBLE CEREBRAL DAMAGE It should be pointed out that head injury with possibIe brain damage is Iooked upon as a contraindication1 to the immediate reduction and fixation of mandibuIar and facia1 fractures if the patient is to be treated under genera1 anesthesia. This is generaIIy true; however, when surgery can be performed under infiItration or nerve bIock anesthesia in borderIine cases of conscious patie’nts with questionabIe cerebra1 damage without endangering the safety of the patient, the resuIt of the operation wiI1 be superior than if surgery were delayed until the period of observation for cerebra1 damage was over. UsuaIIy a fractured, retrodispIaced mandibIe causes respiratory embarrassment due to reIaxation of the structures of the floor of the mouth. We have folIowed the principle of early reduction and adequate immobiIization in the reported cases and beIieve that early treatment has aided in the obtaining of a superior functiona1 and cosmetic resuIt as we11 as aiding the patient’s recovery. OccasionaIIy we are caIIed on to reduce facial fractures after other fractures of the body have been reduced and immobiIized. We believe that moving the patient to the operating room, especiaIIy if traction apparatus has been set up for the other fractures, is unnecessary and often harmful. In these cases one can aIso

ANESTHESIA Premeditation. AI1 aduIt patients in this series received premeditation of demero1, IOO and atropine or scopoIamine, xso gr. i%iturates are not routinely given because of their depressing action on the centra1 nervous system, * however, sodium amyta1 and oxygen a e routineIy avaiIable for immediate use shouId any signs of toxicity be apparent. In no case in this series did these signs of intoxication deveIop. Technic. InfraorbitaI injection is accomplished by an injection of 2 to 3 cc. of unacaine into the infraorbitai foramen which is situated about I cm. below the lower orbita margin, about mid-way between the inner and outer angIes. (Fig. I,) This anesthetizes the Iower eyelid, skin and cartiIage on the side of the nose and the upper lip. The second division of the trigemina1 nerve may be anesthetized by passing the needIe through the buccinator muscIe into the infratempora1 fossa and then into the pterygopalatine fossa where the soIution is deposited. The landmarks of this injection site are the anterior 74

FaciaI

and Jaw

Fractures ovaIe. (Fig. 3.) About 2 to 3 cc. of unacaine are injected after aspirating to see if the needle is in a vessel. This anesthetizes the lower jaw, gum tissue, floor of the mouth, a portion of the cheek and the anterior two-thirds of the tongue.“-”

border of the ramus and the coronoid process of the mandible. Then the base of the zygomatic process of the maIar bone is paIpated and at this place the needIe is directed horizontally at right angles to the cheek, slightly backward clearing the tuberosity and then up-

2

I FIG. I. Diagrammatic

drawing

of technic

3

for infraorbital

injection.

F~ti. 2. Diagrammatic drawing of technic for injection of second division of the trigeminal rotundum; B, maxiIIary division of trigeminal nerve; C, postero-superior dental nerve. FIG. 3. Diagrammatic men ovale.

drawing

of technic

for injection

of mandibutar

ward m-here bone wil1 again be encountered. This wil1 be in the pterygopalatine fossa which is under the greater wing of the sphenoid just below the foramen rotundum. (Fig. 2.) Two or 3 cc. of solution wil1 be sufficient anesthesia for the surgery of the maxiIIary bone, the maxillary sinus, aIveolar process, operations of the soft tissue of Iips, nose and cheek, almost covering the entire side of the face. There are many approaches for the injection of the mandibular division of the fifth nerve. We use the technic for anesthetizing the nerve at its exit from the foramen ovale. One landmark for this procedure is the sigmoid notch, which

may

be Iocated

just

anteriorly

and

below

easily inferior

the

zygoma.

detected

patient’s

by

mouth. border

depression at a right

as a distinct

to the condyle

The

other

of the zygomatic

just described angle

is advanced

The

opening

to the surface

about

landmark arch.

the needle

can

closing

be the

is the Into

OF

nerve

A, foramen

csit ft-urn fora-

REDUCTION

In facial and jaw Anatomic Considerations. fractures the correct dental occlusion is very important because when the occlusion is reestablished the bone fragments are in good functional aIignment. The pull of the muscIes attached to the mandibIe is the chief reason for displacement of the fragments. The masseter, temporal, internal and external pterygoid muscles generally tend to puIl upward and inward. The mylohyoid, digastric and geniohyoid muscles tend to puII downward and inward. The dispIacement of tfle fragments is also caused by the direction and bevel of the fracture line, and by the direction and intensity of the traumatic force. Of the :\fandible and hfaxillary Fractures. twenty-eight fractures of the mandible nineteen were reduced with intermaxilIary splints, four were reduced by open reduction and interosseous wiring, three by circumferential wiring and two by externa1 fixation. AII patients received the aforementioned premeditation and unacaine anesthesia utiIizing the mandibuIar division of the fifth nerve approach previousIy described. All mandibular fractures were re-

depression

condyle

A, mandibular

TECHNIC

of the mandible and

nerve.

ncrw.

this

is inserted

of the cheek and

30 mm.

The needle will generally strike bone and this will correspond to the smooth undersurface of the greater wing of the sphenoid just externa1 to the foramen 75

FaciaI and Jaw Fractures duced and fixed without

discomfort to the patient. For the five fractures of the mandibIe and maxiIIa the foregoing procedure was folIowed plus infraorbital injection and second division bIock of the trigemina1 nerve. The dispIacement in maxiIIary fractures is not as great as in mandibular fractures. The fractured parts are usuaIIy moved downward, IateraIIy and backward. Some maxiIIary fractures are impacted. AIthough dispIacement of the facial bones is not great, sIight dispIacement affects the facia1 contour and is noticeabIe foIIowing injury. Fractures in the maxiIIa may aIter the orbita cavity and cause visua1 disturbances. The genera1 care of maxiIIary fractures is simiIar to that used in mandibular fractures. When both the mandibIe and maxiIIa are fractured, the entire facia1 structure may be so distorted that reduction in stages is necessary. In muItipIe fractures we deIay compIete reduction of the fragments in some cases in order to gain support by taking advantage of partial heaIing and fixation in one area or another. We have found IocaI anesthesia usefu1, and a satisfactory reduction is eventuaIIy obtained by manipuIating different fragments as heaIing progresses. Each type of fracture requires a special type of immobiIization which is found adequateIy discussed in detai1 by Ieading authorities. Fractures of the Nose. In this series five fractures of the nose were reduced under unaCaine anesthesia by injection of a tota of 8 cc. IocaIIy aIong the dorsum and in each nasoIabia1 fold. In addition, most cases required topical anesthesia which was accomplished by packing the nostri1 with pontocaine. The fragments were then manipuIated manuaIIy with straight hemostats introduced in the nostriIs to elevate the depressed fragments. An aIuminum or meta spIint was used for immobiIization. This was fashioned from an ether can which is commonIy avaiIabIe in any hospita1, and is cut to pattern with bandage scissors. This spIint is heId in pIace with adhesive tape and is moIded daiIy to keep the bridge of the nose narrow for five to seven days. Fractures of the Zygoma. Fractures of the zygoma in this series were reduced using the ora approach, a stout eIevator being passed upward behind the zygoma to eIevate the fragment. We believe that this is a simpler ap-

proach than the GiIIies method. Injection of the infraorbita1 nerves pIus deep infIItration in the incision Iines give good anesthesia. Soft Tissue Wounds. We beIieve that soft tissues shouId not be sutured before bony fragments are immobilized for severa reasons. It is aIways possibIe to tear apart a recentIy sutured facia1 wound in the process of stretching the skin in order to gain exposure. This is especiaIIy true in Iacerations around the mouth. SecondIy, an open wound may give exceIIent access to fracture sites if open reduction is necessary. ThirdIy, better aIignment of tissues is aIways accomplished if the bony framework is returned to its origina position before the two edges of a skin Iaceration are Iined up in cIosure. We therefore consider only the contro1 of hemorrhage and cIeansing of the wound before immobiIization of the fracture and then dea1 with the cIosure of the soft tissues themseIves after fixation of the fragments. In Iacerations of the lip a better cosmetic resuIt is obtained with nerve bIock rather than IocaI infiItration in the Iacerated area because IocaI infiItration tends to balloon the tissues out of norma proportions. Postoperative Care. Common pathogens in contaminated wounds can usuaIIy be controIIed with I gm. of streptomycin and 300,000 units of peniciIIin twice a day. 7 We beIieve that ora hygiene is very important in a11 cases invoIving the ora cavity, and recommend phyIorino1 as a mouth wash. SUMMARY

Reported is the treatment of maxiIIofacia1 injuries using a new IocaI anesthetic which is positive in its action, rapid in its induction and profound in its intensity.* We beIieve earIy immobiIization is of great importance and may be accomplished safeIy without the risk of a genera1 anesthetic in patients who have or are suspected to have head injury. This earIy reduction is aIso important, even in cases of possibIe cerebra1 damage, in order to obtain the best cosmetic and functiona resuIts. LocaI anesthesia enables earIy reduction in cases of questionabIe cerebra1 damage which might be impossibIe if genera1 anesthesia were the only agent avaiIabIe. It shouId aIso be pointed out *The anesthetic solution used is available under the trade name unacaine and was generously supplied for this study by the Novocol ChemicaI Manufacturing Co., Inc., BrookIyn, N. Y.

76

Facial that oral treatment

hygiene is very important of facial fractures.

and in

Jaw

Infiltration and General Anesthesia in Dentistry.

the 4.

HEFEKENCES I. I:VAR.S, J. P. Acute head injury. J. A. M.

Fractures

149:

5.

323, ‘952. 2. GRAHAM, J. R. and SCOTT, T. M. Notes on the treatment of tetanus. New England J. Med., 233:

6.

846 1946. 3. Nc:\,~u, kl. and

A.,

7.

PCTEKBALGH, P. G. Conduction,

Revised 5th ed. Brooklyn, 1949. Dental Items of Interest Publishing Co. SUITH, A. E. Block Anesthesia. St. I.ouis, 1920. C. V. Mosby Co. BRAUN, II. Local Anesthesia. Philaclclphia, 1924. Lea &LFebiger. ALLEN, C. W. LocaI and Regional Anesthesia. Philadelphia, 1918. W. B. Saunders Co. Rus~r, J. T. and QLARANTILLO, E. P. ~la~illofacial iniuries. Ann. SW-~., 135: 205, 1952.

IN patients with clinical hyperparathyroidism often a paIpabIe nodule in the neck is absent and x-rays may faiI to show a calcified parathyroid. Since these patients have severe symptoms whether the increased function was due to hyperplasia, adenoma or carcinoma, exploratory operation is indicated. If the hyperfunctioning parathyroid cannot be found and one of the four is absent from its normal anatomic location, subtota1 thyroidectomy is advisabIe on that side since the abnormal gland may be imbedded in the thyroid. If not, the diseased parathyroid may be located in the mediastinum and is usuaIIy found and removed subsequently via sternotomy. It is occasionaIIy found at the site of the thymus gland and any remnant of the thymus should be removed at this same time. (Richard A. Leonardo, M.D.~

77