Facial Trauma

OVERVIEW

Those with facial injuries have a high chance of having other serious injuries:

1. TBI
2. airway obstruction
3. pulmonary contusion
4. aspiration

• mostly blunt

RISK FACTORS

• MVA
• non-restrained
• no airbags
• ETOH

TYPES OF INJURY

• mandibular #
• mid-facial # (Le Fort I -> III #)
• TMJ disruption
• zygomatic, orbital and nasal #
• soft tissue injuries
• haemorrhage
• associated injuries: BOS #, TBI, cervical spine #, carotid injury

MANDIBULAR #

• fractures at the vunerable points (ramus, body at level of 1st and 2nd molar)
• bilateral # can precipitate airway obstruction from posterior displacement of tongue

MIDFACE #

• the nasal cavity, paranasal sinuses and orbits act as a series of compartments that progressively collapse and absorb energy protecting the brain, spinal cord and other vital structures.

Le Fort I

• # involving the maxilla at the level of the nasal fossa
• horizontal plane at the level of the nose
• palate-facial separation

Le Fort II

• maxilla, nasal bones and medial aspect of the orbit involved -> freely mobile, pyramidal-shaped portion of the maxilla (pyramidal disjunction).
• fracture line extend from the lower nasal bridge through medial wall of the orbit, crosses the zygomaticomaxillary process.

Le Fort III

• craniofacial disjunction -> fracture line runs parallel to the base of the skull which separates the midfacial skeleton from the cranium (involves the ethmoid bone and cribriform plate at the BOS)
• fracture line extends through the upper nasal bridge and most of the orbit across the zygomatic arch.

TEMPROMANDIBULAR JOINT

• mechanical impairment may result from condylar or zygomatic arch fracture and can prevent jaw opening (even when paralyzed).

ORBITAL FRACTURES

• severity can vary
• oedema and ecchymosis -> subconjunctival haemorrhage and loss of vision -> ocular rupture
• blow out fracture occurs when pressure directly applied to eye with fracture of inferior bony structures (enophthalmos, diplopia, impaired eye movement, infraorbital hypoesthesia)

NASAL FRACTURES

• prime concerns are epistaxis and septal haematoma

SOFT TISSUE INJURIES

• abrasions, contusions, lacerations
• evolving oedema over 24-48 hours can be massive and potentially threaten airway patency

SEEK ASSOCIATED INJURIES

• Base of skull fracture
• CSF rhinorrhoea (anterior or middle fossa BOS #)
• carotid-cavernous fistula (pulsatile exophthalmos, orbital bruit)
• TBI
• cervical spinal injury
• traumatic occlusion or dissection of internal carotid artery or vertebral artery
• thoracic trauma
• abdominal trauma

MANAGEMENT

Resuscitate

• assess and secure airway (may require cricothyroidotomy/tracheostomy)
• stop bleeding (nasal tampons)

Specific

• open, contaminated wounds: irrigation, debridement, removal of foreign bodies and closure within 24 hours, prophylactic antiobiotics
• early surgery if orbital injury with optic nerve compression is present.
• tetanus
• prophylactic antibiotics for CSF leak are not indicated (still controversial)
• internal fixation usually performed at 4-10 days once swelling has settled

References and Links

FOAM and web resources

• Eponymictionary – Le Fort facial fractures
• Eponymictionary – René Le Fort (1869-1951)
• EMCrit Podcast 112 – Exsanguinating Hemorrhage from Mid-Face Fractures (2013)

Journal articles

• Ceallaigh PO, Ekanaykaee K, Beirne CJ, Patton DW. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 1: Advanced trauma life support. Emerg Med J. 2006 Oct;23(10):796-7. PMC2579603. (Part 1 of 6 on facial injuries)
• Kretlow JD, McKnight AJ, Izaddoost SA. Facial soft tissue trauma. Semin Plast Surg. 2010 Nov;24(4):348-56. PMC3324223.
• Lynham AJ, Hirst JP, Cosson JA, Chapman PJ, McEniery P. Emergency department management of maxillofacial trauma. Emerg Med Australas. 2004 Feb;16(1):7-12. PMID: 15239748.
• Perry M, Dancey A, Mireskandari K, Oakley P, Davies S, Cameron M. Emergency care in facial trauma–a maxillofacial and ophthalmic perspective. Injury. 2005 Aug;36(8):875-96. PMID: 16023907.
• Perry M. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 1: dilemmas in the management of the multiply injured patient with coexisting facial injuries. Int J Oral Maxillofac Surg. 2008 Mar;37(3):209-14. PMID: 18178381.
• Perry M, Morris C. Advanced trauma life support (ATLS) and facial trauma: can one size fit all? Part 2: ATLS, maxillofacial injuries and airway management dilemmas. Int J Oral Maxillofac Surg. 2008 Apr;37(4):309-20. PMID: 18207702.
• Perry M, O’Hare J, Porter G. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 3: Hypovolaemia and facial injuries in the multiply injured patient. Int J Oral Maxillofac Surg. 2008 May;37(5):405-14. PMID: 18262768.
• Perry M, Moutray T. Advanced Trauma Life Support (ATLS) and facial trauma: can one size fit all? Part 4: ‘can the patient see?’ Timely diagnosis, dilemmas and pitfalls in the multiply injured, poorly responsive/unresponsive patient. Int J Oral Maxillofac Surg. 2008 Jun;37(6):505-14. PMID: 18295453.