Facial trauma

Introduction

• Assaults, MVA, falls, sports and gunshot wounds in descending order
• Nasal bones, orbital floor, zygomaticomaxillary, maxillary sinuses and mandibular ramus in descending order
• Urban – Midface and zygomatic fractures (assault and gunshot wounds)
• Rural – Mandible and nose fractures (MVA and recreational)
• Always consider domestic violence, elder and child abuse

Pathophysiology

• Strong vertical buttresses
  • Zygomaticomaxillary buttress laterally
  • Frontal process of maxilla medially
• Weaker horizontal buttresses
  • Superior orbital rims
  • Orbital floor
  • Hard palate
• Inferior and medial walls of orbits are particularly weak
• Protect airway first and foremost
  • Up to 44% of severe maxillofacial trauma patients requires intubation due to mechanical disruption or massive haemorrhage
• Essential tasks are then to identify injury and restore normal appearance, sight, mastication, smell and sensation
  • Up to 6% of patients will suffer visual loss so detailed eye examination is crucial

Primary survey

• Airway – ETT for mechanical disruption or severe haemorrhage
• Circulation – Early packing of nasal/oral cavity. Direct pressure to external wounds. Avoid blind clamping
• 20% of those with facial injuries will have life-threatening associated injuries
  • 15% closed head injury
  • 3.5% airway obstruction
  • 1.5% pulmonary contusion/aspiration

Clinical features

• Secondary survey begins with three screening questions:
  • 1) How is your vision?
  • 2) Is your face numb?
    • Chest for anaesthesia over forehead, lower eyelid, cheek and upper lip or chin (supraorbital/infraorbital/mental nerves)
  • 3) Do your teeth fit together normally?
    • Malocclusion seen with mandibular and maxillary fractures
• Inspect the face from front, sides, feet and above to detect subtle asymmetry
• Full cranial nerve assessment is required (esp. CN VII and V)

Eye examination

• Palpate entire orbital rim for bony step or crepitus (sinus-involvement)
• Examine eyes before swelling occurs
• Visual acuity with Snellen, fingers or nametag
• Loss of vision implies injury to globe or optic nerve
• EOM
  • Binocular double vision suggests entrapment of extraocular muscles, whereas monocular double vision suggests lens dislocation
• Pupil shape, position, symmetry, reactivity

Eye examination

• Note distance between medial canthi (should be same as globe)
  • Telecanthus (widening of distance between medial canthi with normal interpupillary distance) occurs with naso-orbito-ethmoid injuries
  • Hypertelorism (widening of interpupillary distance) results from orbital blow-out injuries, often resulting in blindness
• Check for RAPD (Marcus-Gunn pupil)
  • Sensitive but not specific for optic nerve injury because pathology can be anywhere along visual pathway
• Finish with fundoscopic, slit-lamp and fluorescein examinations
• Check IOP (iCare can only be used holding upright)
• Check for hyphaema after sitting up for a few minutes

Eye examination

• Ophthalmologist repair indicated for:
  • Globe injuries
  • Retro-orbital haemorrhage
  • Hyphaema
  • Vitreous haemorrhage
  • Orbital septal injury
  • Tarsal plate injuries
  • Injuries to medial quadrant involving lacrimal duct

Nose examination

• Check for deformity from multiple angles and ask about any prior injury
• Check for tenderness, crepitus, septal haematoma and CSF rhinorrhoea
  • Septal haematoma is grape-like mass along septum
• Ensure simple nasal fractures are NOT associated with complex naso-orbito-ethmoid injuries
• Classic tests for CSF rhinorrhoea are not specific in the presence of bleeding
  • Double ring or halo sign seen with both CSF and serous nasal discharge in the setting of trauma
  • Nasal discharge doesn’t contain glucose while CSF does but the presence of blood will give a false-positive result

Ear examination

• Battle’s sign
• Auricular haematoma
  • Requires incision and drainage to prevent cauliflower deformity
• External auditory canal for laceration, CSF leak and haemotympanum
• Insert finger into external auditory canal and ask patient to open/close jaw to check for mandibular condyle fracture

Jaw examination

• Malocclusion – LeFort, mandibular, zygomatic fractures
• Check for missing/subluxed teeth, fractures of alveolar ridge, sublingual haematoma or breaks in oral mucosa
• Inspect tongue for lacerations as can swell greatly with time
• Tongue-blade test
  • If patient can bite down and allow physician to twist tongue depressor to break, does not require imaging of mandible
  • 96% sensitive
  • 85% specificity

imaging

imaging

• In Australia, facial CT has largely replaced Waters’ view for frontal or midface suspected #
• Head CT is up to 90% sensitive for mid-facial fractures
  • An additional Waters’ view X-ray is unnecessary if low clinical suspicion in patients undergoing head CT for suspected TBI
• Mandible
  • OPG is 70-86% sensitive in adults and children
    • Requires upright patient and may miss mandibular condyle fractures
  • Mandible CT is 92-100% sensitive
    • May miss fractures of dental root
    • Recommended for patients undergoing head CT for TBI

Airway management

• May be occluded by TBI/intoxication, haemorrhage, bilateral posterior mandible fractures, midface collapse, soft palate swelling or tongue swelling
• Basic airway manoeuvres are crucial
  • Can lift swollen obstructing tongue with gauze
  • Remove avulsed teeth or foreign bodies
  • BVM often requires two-operators due to loss of anatomy and repeated suctioning
  • Once C-spine cleared, sit patient up in position of comfort and give them suction for blood/secretions
• Plan for failed airway

Haemorrhage

• Life-threatening haemorrhage in 10% of mid- and lower facial bleeding
• Nasal packing is fraught with danger in midface fractures due to risk of intracranial placement
• If significant ongoing bleeding despite direct pressure, operative ligation is required
• Arterial embolisation may be an option for ECA branch control

Frontal bone fractures

• Uncommon and associated with high-energy MOI
• Increased risk of TBI, other facial fractures and C-spine fracture
• Concomintant craniofacial injuries are seen in 56-87% of frontal sinus #
• Ocular injuries seen in 25%
  • RAPD seen in 10% of patients
• Dura is adherent to posterior table of sinus, so operative repair is required for through-and-through frontal sinus fractures to prevent pneumocephalus, CSF leak and infection
• Oral antibiotics (cephalexin or augmentin) recommended for any sinus fracture
• Isolated anterior table sinus fracture
  • Nasal and oral decongestants and appropriate follow-up on discharge
• Depressed fractures – Admit for IV antibiotics and operative repair

Orbital fractures

• Anatomy
  • Superior – Frontal bone
  • Lateral – Zygoma and sphenoid
  • Inferior – Zygoma and maxilla
  • Medial – Ethmoid bone (lamina papyracea)
• Pure/blow-out fractures
  • Involves only the orbital walls when object of small diameter strikes the globe without causing an orbital ridge or rim fracture
  • Get force transmitted by globe to weak medial and inferior walls
  • Adipose tissue, inferior rectus or inferior oblique can herniate into maxillary or ethmoid sinuses
• Lateral, inferior and superior orbital ridge fractures tend to occur with other facial fractures
• Significant force to the nasal bridge can cause complex naso-orbito-ethmoid fractures accompanied by injuries to lacrimal duct, dural tears and TBI

Orbital fractures

• Key examination findings
  • Enophthalmos (pushed in)
  • Step off or crepitus of orbital rim
  • Infraorbital anaesthesia
  • Diplopia on upward gaze with entrapment of inferior rectus, inferior oblique or orbital fat OR injury to muscles or oculomotor nerve
  • Pain on eye movement
  • Traumatic telecanthus
  • Epiphora (tears spilling over lower lid)
  • CSF leak
• Radiographic findings
  • Teardrop sign of herniation, fluid in sinus

Orbital fractures

• Isolated orbital fracture
  • Augmentin, decongestants, sinus precautions
  • D/W MaxFax prior to d/c as controversy exists around timing of repair
• Emergent ophthalmology review
  • Retrobulbar haematoma or malignant orbital emphysema may create ocular compartment syndrome leading to acute ischaemic optic neuropathy
  • Examination may show exophthalmos, decreasing visual acuity and increased IOP
  • Emergency lateral canthotomy reduces ocular pressure and ischaemia
• Orbital fissure syndrome
  • Fracture of superior orbital fissure with injury to oculomotor and ophthalmic divisions of CN V
    • Paralysis of EOM, ptosis and peritorbital anaesthesia
  • Orbital apex syndrome
    • Optic nerve also involved resulting in orbital fissure syndrome + reducing visual acuity

Lateral canthotomy – DIP A CONE G

• Primary indications
  • Decreased visual acuity
  • IOP >40
  • Proptosis
• Secondary indications
  • Afferent pupillary defect
  • Cherry red macula
  • Ophthalmoplegia
  • Nerve head pallor
  • Eye pain
• Contraindications 
  • Globe rupture

Lateral canthotomy

• LA infiltration to lateral eye region
• Crush lateral canthus with clamp to devascularise for 1 minute
• Canthotomy
  • Place scissors across lateral canthus and incise canthus full thickness towards orbital rim on side
• Cantholysis
  • Grasp lateral lower eyelid with toothed forceps
  • Pull lower eyelid anteriorly
  • Place blades either side of lateral canthal tendon (feels like guitar string) and cut (start inferiorly and if needed cut the superior part as well)

Zygmoma fractures

• Zygomatic arch fractures occur with anterior and lateral force
• Zygmomaticomaxillary (tripod) fractures result classically from high energy deceleration injury with disruption of:
  • Zygomaticofrontal suture
  • Zygomaticotemporal junction
  • Infraorbital rim
• This is considered an orbital and sinus fracture requiring IV antibiotics and inpatient repair
• Examination
  • Flattening of malar eminence in the absence of often significant swelling
  • Trismus may result from masseter spasm or mechanical impingement of temporalis muscle or coronoid process of mandible
• Isolated temporal arch – d/c with appropriate medications and MaxFax f/u
• Zygomaticomaxillary fractures with any loss of vision or significant displacement require admission for IV Ab’s and operative repair

Midfacial fractures

• Maxillary fractures require considerable force
• LeFort injuries 
  • Often present with dramatic haemorrhage, early swelling, bilateral orbital ecchymoases and CSF leaks in II/III
  • Rarely occur in pure form. Usually mixed i.e. right LeFort I and left LeFort II)
  • LeFort I
    • Transverse fracture separating the body of the maxilla from the pterygoid plate and nasal septum
    • Only the hard palate and teeth move (like loose upper denture)
  • LeFort II
    • Pyramidal fracture through central maxilla and hard palate
    • Hard/palate and nose move but NOT eyes
  • LeFort III
    • Craniofacial dysjunction with fractures of frontozygomatic suture line, across the orbit and through base of nose and ethmoids
    • Entire face shifts with globes held in place only by the optic nerve
    • May transects cribriform plate and base of skull
  • LeFort IV
    • LeFort III + Frontal bone involvement

Lefort

Mandible fractures

• 36% at angle; 21% in body; 17% in parasymphyseal region
• Always look for second fracture on other side of ring
  • Bilateral until proven otherwise (64%)
  • Respiratory obstruction may occur after bilateral angle or body fractures due to posterior displacement of the tongue “Andy Gump fracture”
• Presume open fracture until thorough intra-oral examination proves otherwise
• Favorable if musculature reduces the fracture
• Unfavorable if musculature opens the fracture
• Intra-oral exam for
  • Mucosal lacerations, sublingual haematoma, dental or alveolar ridge fractures and any missing teeth
• Examine ears for TM perforation, haemotympanum, evidence of condyle displacement (finger in the ear) and external auditory canal laceration

Last Updated on October 9, 2020 by Andrew Crofton