Facial Trauma
Derreck Raimo, MD, FACEP
Jacobi Medical Center
Department of Emergency Medicine
Ocular Trauma
Anatomy of the eye
·Six extraocular muscles
are responsible for all
ocular movement
·Controlled by cranial
nerves
·Ocular motility can be
impaired by restriction,
denervation or trauma
Ocular Trauma
Anatomy of the eye
·The conjunctiva, cornea,
anterior chamber, iris, lens
and ciliary body are
referred to as the anterior
segment
· The sclera is referred to
as “the white of the eye”
·The body of the eye is
referred to as the globe
Ophthalmologic exam
·Inspection
·Pupils
·Movement
·Acuity
·Anterior Chamber
·Visual Fields
·Fundoscopy
Subconjunctival Hemorrhage
·Conjunctival vessels are
fragile and can rupture
from minor trauma
·The blood is usually bright
red and appears flat
·Painless
·Requires no treatment
Corneal Abrasion
·Abrasion of the
corneal epithelium
usually caused by
direct trauma
·Very painful, tearing,
foreign body sensation
·Can only be visualized
using fluorescein dye
under cobalt blue light
Corneal Foreign Body
·Patients complain of a foreign body sensation following an
appropriate event
·Superficial FBs can be removed using a cotton applicator
·Imbedded FBs must be removed under magnification with
a 25ga needle or eye spud
·Failure to remove metallic FBs in a timely fashion may
result in a rust ring
Hyphema
·Any injury to the anterior
chamber can disrupt the
vasculature supplying the iris
or ciliary body
·Can cause pain, blurry vision
and photophobia
·Initial treatment is aimed at
preventing further bleeding
·Have the patient rest in the
supine position with the
head slightly elevated
·Use a rigid eye shield when
possible
Chemical Injury
·True ocular emergency
·Identify exposure agent if possible
·Immediate copious irrigation with
normal saline should not be
delayed
·Can use a Morgan Lens or a liter
bag of NS attached to a nasal
cannula
·Alkali exposure (lye, ammonia) is
worse than acid, but both can be
blinding
Cyanoacrylate
·Super glue, “Crazy Glue” or
Dermabond
·Accidental application to the
eye is common, especially in
children
·Can adhere lids together and
forms clumps on the cornea
or sclera
·Glue can be moistened and
removed using Erythromycin
ointment
Globe Rupture
·Commonly caused by penetrating
trauma, but can also occur by blunt
mechanisms
·Suspect when a large FB protrudes
from near the globe
·Such objects should be left in place
·Avoid any manipulation of the globe,
apply a rigid shield if possible
·Diagnosis suspected with teardrop
shaped pupil, flattened anterior
chamber or obvious aqueous humor
leakage
·Diagnosis confirmed by Seidel Test
Globe Rupture
Globe Rupture
Globe Rupture
Rigid Eye Shield
Bulky Dressing
Traumatic Iridodialysis
·Trauma can pull the iris
away from the ciliary
body
·Patients complain of a
“second pupil”
·Commonly associated
with hyphema or lens
dislocation
·No specific emergency
treatment
Lens Dislocation
·Caused by a sudden
blow to the globe
·Patient complains of
double vision or gross
blurry vision
·Must be surgically
corrected
Dental Trauma
Dental Fractures
·Classified as Ellis class I, II,
and III
·Class I involves the enamel
only
·Class II involves the enamel
and exposes underlying
dentin
·Class III fractures extend into
the pulp
Dental Fractures
·Ellis class I
·Involves the enamel only
·Treat pain and any
underlying lacerations
·Predominantly cosmetic
issue
Dental Fractures
·Ellis class 2
·Deep enamel disruption
exposes dentin
·Pulp can become infected
over time
·Gauze dressing placed over
tooth can ease pain if the
nerve is exposed and help
prevent infection
Dental Fractures
·Ellis class 3
·Dental Emergency
·Delay in treatment by
dentist can result in severe
pain and abscess formation
·Noticeable pink or bloody
discoloration on the fracture
surface is diagnostic
Dental Subluxation
·Loosening of a tooth in its
alveolar bone socket
·Unstable teeth can be
temporarily immobilized with
·Gauze
·Suture material in a figure
eight around adjacent tooth
·Aluminum foil
·Periodontal dressing
Dental Avulsion
·Total displacement of tooth from its
socket
·Involves complete disruption of the
periodontal ligament
·Successful implantation depends on the
survival of periodontal ligament fibers
·Rinse tooth with saline but do not scrub
·Store in Hank’s Solution if possible if not
Patients mouth > container of milk >
normal saline
·Do not use water to store tooth
Nasal Trauma
·Commonly results in epistaxis
·Hold continuous pressure to
soft portion of nose
·Homemade or commercial
clips can be handy
·Anterior bleeds are most
common
·Posterior bleeds can be life
threatening
Septal Hematoma
·Uncommon complication of direct
trauma to nose
·Blood accumulates between
mucosal skin and underlying
cartilage
·The resulting pressure on septal
cartilage can lead to necrosis and
deformity
·Must be drained by a surgeon
Cranial Trauma
·The scalp is comprised of 5 layers.
Skin, subcutaneous tissue, galea,
areolar tissue and pericranium
·The skull is comprised of eight major
bones
·The scalp’s rich vascular supply
causes a potential for severe blood
loss from seemingly minor lacerations
·Skull fractures are classified as either
basilar or of the skull convexity
Basilar Skull Fracture
·The most common type involves
the temporal bone
·Commonly associated with a tear
in the dura leading to a CSF leak
·Classic signs and symptoms are
often absent on initial presentation
but will develop gradually over the
first hours of evaluation
·Raccoon Eyes are caused by
bleeding from a fracture site in the
anterior portion of the skull base
Basilar Skull Fracture
Battle’s Sign
Hemotympanum
Depressed Skull Fracture
·Commonly occurs when a
large force is applied to a
small area
·Classified as an open
fracture if fracture lies
below or near a laceration
·Wound must be explored
and manipulated in a sterile
fashion
Frontal Bone Fracture
·All frontal lacerations must
be explored to rule out an
underlying fracture
·A fracture will involve the
frontal sinus
·May be part of a complex of
facial fractures involving
other sinuses
Maxillofacial Trauma
·Sutures at the borders of
the sphenoid bone,
pterygoid plate and
zygomatic arch anchor the
face to the skull
·The orbit consists of 7
different bones
·Orbital bones lie in close
proximity to extraocular
muscles, vessels and cranial
nerves
Maxillofacial Trauma
·Prehospital care should concentrate on control of the airway
·Always maintain c-spine precautions
·The mouth should be cleared of any obvious debris and
suctioned as needed
·Severe mandibular fractures may prevent a jaw thrust from
clearing the tongue from airway, necessitating manual extraction
of the tongue with a gauze pad, towel, clamp, or even a suture
through the anterior tongue
·Early emergency department notification helps us to prepare
Maxillofacial Trauma
·Avoid nasotracheal intubation in patients with midface trauma because the
cribiform plate may be disrupted
·Orotracheal intubations are often successful even with distorted facial
anatomy
·It may be impossible to obtain an adequate seal with a BVM
·Laryngeal mask airway can be considered in a difficult airway
·When possible prepare for a surgical airway while attempting intubation
·Control bleeding with direct pressure
·Severe pharyngeal bleeding may require packing of the pharynx above a
cuffed ET tube
·In LeFort fractures manual reduction may be needed to control bleeding
Maxillary Fractures
·An impact 100 times the force of
gravity is required to break the
midface
·Classified as LeFort fractures
·LeFort I fractures involve only the
area under the nasal fossa
·LeFort II fractures involve a
pyramidal area including the maxilla
zygoma, nasal and ethmoid bones
·LeFort III fractures are known as
craniofacial disassociation and
involve the frontozygomatic suture
at the base of the skull
Maxillary Fractures
·Clinically a patient will have
significant facial swelling and
ecchymosis
·Associated cranial injuries
are common
·Airway protection
·Hemorrhage control
·Cervical immobilization
Zygoma Fractures
·Visual inspection from
several angles may detect a
subtle deformity
·Can be associated with
orbital fractures and ocular
trauma
Orbital Fracture
·Occurs when the globe sustains a
direct blunt force
·In a true orbital blowout fracture
this force is transmitted to the
thin bones of the orbital floor
resulting in a fracture
·May result in entrapment of
extraocular muscles if they
herniate through the fracture
·Fractures without entrapment or
associated globe injury are treated
conservatively
Mandibular Fracture
·Results in malocclusion or
irregular contact between upper
and lower teeth when mouth is
closed
·A non fractured mandible should
be able to hold a tongue blade
between the molars tightly
enough to break it off
·A unilateral condylar fracture will
deviate the jaw towards the side
of the fracture upon maximal
opening
TMJ Dislocation
·Temporal Mandibular Joint
·Can result from direct trauma
to chin while mouth is open
·Can occur in predisposed
individuals during a vigorous
yawn, eating or laughing
·Approximately 70% of the
population can partially
subluxate then spontaneously
reduce the mandible
TMJ Dislocation
·
References
·Tintinalli, J., Kelen, G. D., Stapczynski, J. S. Emergency
Medicine a Comprehensive Study Guide. 5th Ed. McGraw-Hill,
1985.
·Marx, J. A., et al. Rosen’s Emergency Medicine Concepts and
Clinical Practice. 5th Ed. Mosby, 1998
·Knoop, K. J., Stack, L. B., Storrow, A. B. Atlas of Emergency
Medicine. 2nd Ed. McGraw-Hill, 2002