FACIAL TRAUMA
INTRODUCTION
Up to 60% of facial trauma patients have associated injuries
20-50% brain injury
1-4% C spine injury
0.5-3% blindness (most commonly with Lefort II and III)
Remember spouse abuse (most common injury is to orbital rim) and child abuse
25% of patients with facial trauma will go on to develop PTSD
MECHANISM
High impact
Supraorbital rim 200G (multiples of gravity)
Symphisis of mandible 100G
Angle of mandible 70G
Frontal Bone 100G
Low impact
Zygoma 50G
Nasal bone 30G
MANAGEMENT
Key concept is to manage airway and look for associated injuries
AIRWAY (most important part of management)
Look, listen and feel
Chin lift, jaw thrust
Manually displace tongue forward. Consider OPA
Maintain C spine immobilization
Avoid nasotracheal intubation because of possible cribriform plate fracture
Use RSI cautiously b/c might be a difficult airway
Consider awake intubation with ketamine or fibreoptic intubation
Don’t be a hero- call for backup, prepare for cricothyroidotomy
HEMORRHAGE CONTROL
Facial bleeding should not cause shock or hypovolemia – look for another source
3 areas that bleed:
Maxillofacial bleeding: control with direct pressure, don’t blind clamp
Nasal bleeding: consider anterior or posterior packing
Pharygneal bleeding: pack around the ET tube
HISTORY
Same as a general trauma history
Specific questions for facial trauma
Is there pain with eye movement? injury to the globe, orbital bones
Are there areas of numbness or tingling on your face?-nerve entrap or laceration
Is the patient able to bite down without any pain?
Is there pain with moving the jaw?- fracture or impingement
PHYSICAL EXAM
Bird’s eye view and Worm’s eye view
Palpate supra and infraorbital rims
Globe: enopthalmus or exothalmus, abnormal shape of pupil, subconjunctival
hemorrhage, visual acuity
Check cornea for abrasions, anterior chamber for hyphema
Fundoscopy to assess retina
Lids- look for lac. Injuries to medial 1/3 may involve lacrimal apparatus
Palpate the medial orbit area to r/o naso ethmoidal orbital fx. (Q tip inside the nose
directed towards the medial canthus, place your finger outside the medial canthus. If the
bone moves NEO #.)
Palpate zygomaticofrontal suture, zygomaticotemporal suture and arch
Palpate nose: asymmetry, widening of nasal bridge (telecanthus- normal intercathi
distance is 32-34mm), septal hematoma, blood, deformity, crepitus, subq air and CSF –
halo sign on paper towel
Palpate maxilla for facial instability/mobility
Palpate mandible for tenderness, swelling and step off
Cranial nerve exam- most important- EOM and facial nerve
Intraoral exam:
Inspect the teeth for malocclusions, bleeding and step-off.
Must account for all teeth.
Manipulate each tooth, check for gum lacerations,
Tongue blade test. (twist tongue blade while pt bites down. If jaw broke, pt will
open mouth) 95% sens and 65% spec.
Palpate the mandible for deformities, step-offs, tender areas
RADIOLOGY
Xrays are useful for assessment of:
Bones, fluid-filled spaces, herniation of orbital contents, subQ air
Basic Facial Series
1)Water’s: (occipitomental view): Single best xray, good screening view for
maxillary #. 37o caudal to canthomeatal line- good to see superior and inferior
orbital rims, nasal bones zygoma and maxilla
2) Caldwell view (PA or occipitofrontal view): 15o caudal to canthomeatal line frontal sinus and supraorbital rim
3)Lateral view – anterior wall of frontal sinus and maxillary sinus views
4)Submentovertex view:occasionally done. Good for zygomatic arch
Jaw series: 1) PA, 2) lateral obliques, 3) Towne’s view and 4) panorex ( best view of
mandible)
CT face
Better than Xray; gold standard for facial fractures
Indicated if
# suspected on exam
Can’t cooperate well for x-ray
Penetrating injury
FRACTURE/DISLOCATIONS
FRONTAL SINUS FRACTURES
Palpate along frontal bone and supraorbital rim for deformity or subq air
Associated with dural tears, intracranial injury and injury to orbital roof
MUST evaluate posterior wall of sinus with CT
Non displaced anterior wall: abx, should still consult neursurg for outpatient followup
Depressed anterior wall or posterior wall fractures- assume to have assoc dural tear
Admit
Neurosurg consultation
Abx and tetanus
Complications of posterior wall fracture: mucocele, CSF leak, epidural empyema,
meningitis, associated orbital fracture
MAXILLARY FRACTURES- LeFort fractures
High force mechanism, consider associated injuries
LeFort Classification (rarely isolated, most commonly occur in combination)
LeFort I - maxilla at level of nasal fossa
Maxilla mobile, nasal bridge stable
Malocclusion of teeth
LeFort II - maxilla, nasal bones, medial aspect of orbits (pyramidal dysfn)
nose and upper jaw mobile on exam
LeFort III - maxilla, zygoma, nasal bones, ethmoid,
vomer, cranial base (craniofacial dysfunction)
dish face deformity ( elongation of eyes with flat sunken face)
At risk for airway obstruction
Management : plastics consult for OR
Airway is most important: ETT –> cric
Rhinorrhea uncommon with I, more common with LF II/III
admit for abx prophylaxis (not proven)
and elevation of head of bed 40-60% if C spine cleared
ZYGOMATIC FRACTURES
2nd MC facial #
Two types: arch and tripod
Arch fracture
Pain over arch +/- bony deformity
Pain with opening mouth or impingement of temporalis muscle/coronoid process
Look for flattened cheek
Submental view (bucket handle view)
Management: refer for outpt ORIF
Tripod fracture
Fracture through 1) arch (or zygomaticotemporal suture) 2) zygomaticofrontal suture 3)
infraorbital rim and floor
Presents with flat cheek, infraorbital nerve damage (anesthesia), diplopia, change in
consensual gaze, step defect, globe injury
Water’s is best Xray but you should CT face
Refer for ORIF (may be outpt if non displaced and without eye involvement)
NASO-ETHMOIDAL-ORBITAL FRACTURE
Suspect if trauma to nose or medial orbit
Pain with EOM
Associated lacriminal disruption and dural tears
Look for flat or saddle shaped nasal bridge, telecanthus, epistaxis or CSF rhinorhea
Q tip test
Needs CT
Consult plastics
Abx?
ORBITAL BLOWOUT FRACTURES
Can be isolated or combined (commonly with zygomatic #)
Blow out fracture: force transmitted to thin orbital floor (or medially)
Direct globe pressure from object < 5 cm radius.
Also from direct blow to infraorbital rim that causes orbital floor to buckle
Possible herniation of fat or muscle into maxillary sinus (tear drop sign)
Presentation
Step off of infraorbital rim
Diplopia due to muscle/fat entrapment, intramuscular hematoma, V2 neuropraxia
True entrapment will be vagal, vomiting, refuse to move eye
Enopthalmos (sunken eye) and limited EOM (limited upward gaze)
Infraorbital anesthesia
Orbital emphysema
Should have a CT but on xray look for
Tear drop sign (herniated fat into maxillary sinus)
Open bomb bay sign (bony fragments protrude into maxillary sinus)
Air fluid level in sinus
Management
Refer to plastics and ophthalmology
Tetanus and abx
Avoid valsalva
Decongestant for 3 days
Most observe for 10 - 14d then decide on OR based on enopthalmos/diplopia
Orbital emphysema
May present with visual acuity loss b/c of pressure on orbit causing central
retinal artery occlusion
Emergent decompression with needle or canthotomy w/ cantholysis
NASAL FRACTURES
MC facial # - 3 kinds: nondisplaced, depressed and laterally displaced
Ask pt if they have broken nose before, how is your breathing, does it look normal
Crepitus, deformity, swelling, tenderness, edema
Epistaxis usually mild but can be heavy
Clinical dx: NO Xrays although can sometimes see on facial lateral xray
Management
Pack bleeding
R/o septal hematoma: drain, pack, ENT follow up if present
Immediate reduction: can do if full edema not yet dev’t (within 3 hours)
Delayed reduction: if already dev full edema- refer for reduction in 6-10 days
If you choose to reduce- intranasal cocaine, bilateral infraorbital nerve blocks and
bilateral external nasal nerve. Use boies elevator or scalpel handle to elevate depressed
bone and forceps to reduce deviated septum
Peds: do not reduce, refer for evaluation in 4/7
Consider assoc injuries: Bridge of nose: nasoethmoid # -----> rhinorrhea, CT face, abx,
neurosurg consult
MANDIBULAR FRACTURES
Mandibular pain/tenderness, malocclusion, separation of teeth, periauricular pain
Trauma + malocclusion = mandibular #
Ecchymosis on floor of mouth very suggestive
Multiple locations in > 50%; may be distant from site of trauma
Locations
Condylar 35%
Body 21%
Angle 20%
Symphysis 14%
Ramus 3%
Coronoid 3%
Panorex view best
CT may be needed for condylar #
Non-displaced: soft diet, analgesic, orif in 1-2 days
Displaced and open #’s are closed sooner
Antibiotics if open: usually penicillin
MANDIBULAR DISLOCATIONS
Risks
Weak TMJ
Shallow articular eminence
Overstretched joint capsule
Neuromuscular disorders
Trauma to jaw
Excessive mouth opening
Mostly anterior but posterior (direct blow to chin), lateral (associated with fracture) and
superior can occur
Mostly bilateral
For anterior: jaw will jut out forward and will deviate away from dislocated side if
unilateral
Muscles of mastication spasm preventing spontaneous reduction
X-ray if mechanism suggests potential #
To reduce: Thumbs or fingers in buccal sulcus or wrapped in gauze on mandibular teeth
Downward backward pressure with rotation so chin goes upward and angle of mandible
goes backcward
May be easier to reduce one side at a time
D/C home with soft diet x 2wks and outpatient F/U with oral surgery
WOUND MANAGEMENT
Don’t forget tetanus
May close facial lacerations up to 24hrs
Indications for delayed primary closure
Wound older than 24 hrs
FB that can’t be removed
Severe contamination can close early if thoroughly debride but if > 6 hours, should
treat with abx for 4 days and then close
Presence of # requiring further evaluation/therapy
When to consult plastics?
Uncomfortable w/ lac
Underlying nerve injury
Injury requiring OR
Delayed primary closure
Wound Management
Avoid epi in ear, nose, tarsal plate of eyelid
Regional blocks, LAT useful
Vigorous scrubbing for abrasions to prevent traumatic tattooing
Careful exploration for FB
Copious, forceful irrigation
Deep: 4-0, 5-0 vicryl
Skin: 5-0, 6-0 prolene/ethilon
No drsg, polysporin, remove 3-5d (minimizes scar)
Indications for antibiotics in facial injuries
Bite wounds
Devascularization
Through-and-through buccal mucosa
Cartilage involvement (nose/ear)
Extensive contamination
SPECIFIC INJURIES
Always consider nerve blocks
Lips
Close vermillion border first
Tongue
Close big lacs and flaps, midline lacs, avulsions, nonlinear lacerations
Oral cavity
Refer if salivary ducts involved
Ear
Auricular nerve block
Approximate cartilage with 5-0, 6-0 absorbable;
Staph abx coverage b/c avascularity of cartilage is high risk for condritis
Subperichondral hematoma: will develop “cauliflower” ear if not drained;
aspirate and compressive dressing for 7d with close f/u and repeat aspiration prn
Periorbital
Refer to optho: lid margin and medial canthus lacs
Through-and-through cheek
Begin intraoral and work outwards
Copious irrigateion after each layer closed
Abx prophylaxis
Eyelid
Plastics for lid margin, canalicular, lacrimal
6-0 Ethilon for superficial lacs
Retro orbital hematoma
-proptosis, decreased visual acuity, IOP > 40, afferent papillary defect
Management: time is EYE therefore pt needs lateral canthontomy
Lateral canthotomy steps:
Local anesthesia and sedation
Crimp skin downward from lateral eye with kellys to reduce bleeding x 1 minute
Cut the skin (canthotomy)
Lift inferior skin flap to identify tendon (tendon feels like guitar string)
Cut the tendon (cantholysis)
Goal IOP < 40
Repeat same steps for superior lateral canthal tendon