Facial Trauma

Patient with self-inflicted shotgun wound of face

Same patient after first reparative surgery

Facial Trauma : Lecture Outline

ƒ Emergency managementƒ Facial examƒ Fractures

–Major–Minor

ƒ Soft tissue injuriesƒ Unusual injuries

Facial Trauma : Causes of Mortality

ƒ Acute–Airway compromise–Exsanguination–Associated intracranial or Cervical-spine injury

ƒ Delayed–Meningitis–Oropharyngeal infections

Facial Trauma : Epidemiology

ƒ Estimate of 3,000,000 facial trauma cases per year in U.S.

ƒ ? 40 to 50 % of MVA victims have facial injury

ƒ No uniform reporting or registry of cases

What Are the Functions of the Face ? (these are disrupted by trauma)

ƒ Respiratory–Upper airway

ƒ Visualƒ Olfactoryƒ Masticationƒ Cosmeticƒ Communicationƒ Individual recognition

Facial Trauma : Emergency Management Sequence

ƒ Airway control / immobilize C-spineƒ Bleeding controlƒ Complete the primary surveyƒ Secondary survey

–Consider NG or OG tube placementƒ Plain radiographs if fractures suspected

–Consider computed tomography if complex fractures suspected

ƒ Immediate soft tissue repair if no other injuriesƒ Delay soft tissue repair till patient in O.R. if

surgery for other injuries necessary

Facial Trauma : Initial Emergency Managementƒ Step 1 : Airway control

–Oxygen for all patients–May need to keep patient sitting or prone–Large bore (Yankauer) suction should be available–Orotracheal intubation preferred over nasotracheal if possible midfacial fracture and invasive airway needed–Stabilize C-spine early–Combitube, retrograde wire, or cricothyroidostomy if unable to orotracheally intubate

Facial Trauma : Initial Emergency Management (cont.)ƒ Step 2 : Bleeding control–Bleeding into airway can be the major threat to life–Remember to use universal precautions–Direct pressure dressings best initially–Blind clamping of vessels contraindicated–Occasionally rapid nasal packing necessary ; if done, make sure blood is not just running down the posterior pharynx–Rarely emergent cutdown and ligation of the external carotid artery needed to prevent exsanguination

ƒ Note : Although shock in a facial trauma patient is usually due to other injuries, it certainly is possible to bleed to death from a facial injury

Causes of Airway Compromise With Facial Traumaƒ Blood in airwayƒ "Debris" in airway

–Vomitus–Avulsed tissue–Teeth / dentures–Foreign bodies

ƒ Pharyngeal or retropharyngeal tissue swelling

ƒ Posterior tongue displacement from mandible fractures

Secondary Survey : Exam Sequence for Facial Traumaƒ Scalp

–Check for lacerations, hematomas, stepoffs, tenderness–May continue brisk bleeding until sutured–Can use stapler for rapid closure

ƒ Ears–Check pinnae, canal walls, TM's–Suction gently under direct vision if blood in canal–Check drop of canal fluid on filter paper for "ring sign" indicating CSF leak–Assess hearing

Auricular hematoma

Requires incision and drainage and compressive dressing

(to prevent pressure necrosis of the auricular cartilage and development of a “cauliflower ear”)

Exam Sequence for Facial Trauma (cont.)ƒ Overall facial appearance

–Assess for symmetry, deformity, discoloration, nasal alignment–Palpate forehead & malar areas

ƒ Eyes–Check pupils, anterior chamber, fundi, extraocular movements–Check conjunctivae carefully for foreign bodies–Palpate orbital rims–Avoid palpation of globe if possible globe penetration–If lid injury leaves cornea exposed, prevent corneal ulcer with use of artificial tears or cellulose gel

Exam Sequence for Facial Trauma (cont.)

ƒ Nose–Check septum for hematoma & position–Check airflow in both nares–Palpate nasal bridge for crepitus–Check fluid on filter paper for "ring sign" (for CSF leak)

ƒ Mouth –Check occlusion–Reflect upper & lower gingiva–Check Stenson's duct for blood–Palpate along mandibular and maxillary teeth (be careful !)–Palpate along exterior of mandible–Pull forward on maxillary teeth

Malocclusion from mandibular fractures

Exam Sequence for Facial Trauma (cont.)

ƒ Neurologic : Assess for :–Sensation in the 3 divisions of the trigeminal nerve–Sensation on tongue–Gag reflex–Motor of each division of facial nerve–Skin fold symmetry at rest

Standard Radiographs for Facial Trauma

ƒ PA skull : undistorted frontal projectionƒ Lateral skull : side view of sinuses & facial

bonesƒ Caldwell view : (PA 15 degrees caudally) :

Visualizes orbital structures without petrous bone overlap

ƒ Towne's view : (AP 30 degrees caudally) : Shows mandibular condyles & orbital floor

ƒ Water's view : (PA of face) : Best single film for maxillary sinuses, orbital floors, & zygoma

ƒ Axial view (submento-vertex) : Best shows zygomatic arch & body of zygoma

Patient positioning for straight PA view of the skull

PA view of skull

Patient positioning for Caldwell’s projection of the skull

Patient positioning for Towne’s projection of the skull

Extended Towne’s view

(note mandibular condyle dislocation on the right)

Patient positioning for Water’s projection (PA of the face)

Water’s view of the face

Patient positioning for axial (submentovertex) view of the face

Axial (submentovertex) view of the face

"Secondary" Radiographs for Facial Trauma

ƒ Mandible : AP, lateral, obliques–Panorex best if available

ƒ TMJ films : for suspected condylar or subcondylar fractures or unexplained malocclusion

ƒ Nasal film : lateral & AP (AP seldom adds information)

ƒ Conventional tomography : useful for orbital floor fractures if computed tomography not available

ƒ Computed tomography : best for complex or multiple fractures

ƒ CXR : if teeth missing (rule out aspiration)

3 dimensional reconstructed computed tomography (same patient as shown at the beginning of the lecture ; note artifact from metal dental fillings)

Classification of Facial Fractures

ƒ Major–Lefort I, II, & III–Mandibular

ƒ Minor–Nasal–Sinus wall–Zygomatic–Orbital floor–Antral wall–Alveolar ridge

Lefort Facial Fractures

ƒ The Lefort types of fractures can coexist with additional facial fractures

ƒ The patient may have a different Lefort type fracture on either side of the face

A : Lefort I B : Lefort II C : Lefort III

Simple Scheme to Differentiate the Types of Lefort Fractures

ƒ Pull forward on the maxillary teeth :–If just the maxilla moves : Lefort I–If the maxilla & base of nose move : Lefort II–If the whole face moves : Lefort III

Lefort I Fracture (Nasomaxillary Fracture)ƒ Definition : horizontal fracture

extending thru the maxilla between floor of the maxillary sinus & orbital floor

ƒ Signs and symptoms–Crepitus over maxilla–Open bite–Ecchymosis in buccal vestibule–Epistaxis, can be bilateral–Malocclusion–Mobility of maxilla

Lefort I Fracture : Treatment

ƒ Closed reductionƒ Intermaxillary fixation (secures

maxilla to mandible)ƒ May need wiring or plating of

maxillary wall and / or zygomatic arch

ƒ Antibiotics (anti-staphylococcal)

Arch bars in a patient with a maxillary fracture

Lefort II Fracture (Pyramidal Fracture)

ƒ Definition : subzygomatic midfacial fracture with a pyramidal-shaped fragment and separated from the cranium and lateral aspects of the face

ƒ Signs & symptoms–Crepitus over midface–Lengthening of face–Malocclusion–Bilateral epistaxis–Infraorbital paresthesia–Ecchymoses : Buccal vestibule, periorbital, subconjunctival

Coronal CT of a Lefort II fracture

Lefort II Fracture : Treatment

ƒ Hemorrhage or airway obstruction may require emergent surgery

ƒ Treatment can often be delayed till edema decreased

ƒ Usually require :–Intermaxillary fixation–Interosseous wiring or plating of infraorbital rims, nasal-frontal area, & lateral maxillary walls–May need additional suspension wires–Antibiotics

Lefort III Fracture (Craniofacial Dissociation)

ƒ Definition : bilateral suprazygomatic fracture resulting in a floating fragment of the mid-facial bones, which are totally separated from the cranial base

ƒ Signs and Symptoms–Lengthening of face (often "caved-in" or "donkey face" appearance)–Malocclusion–Lateral orbital rim defect–Ecchymoses : Periorbital, subconjunctival–Bilateral epistaxis–Infraorbital paresthesia–Often medial canthal deformity–Often unequal pupil height

Patient with Lefort III fracture ( note telecanthus and face lengthening)

“Donkey-face” appearance of Lefort III fracture

Motion of mid-third of face suggesting Lefort II fracture

Multiple fracture plates used to treat a complex set of facial fractures

Lefort III Fracture : Treatment

ƒ Usually associated with major soft tissue injury requiring emergent surgery for bleeding control

ƒ Surgery can be delayed till edema resolvesƒ Intermaxillary fixationƒ Transosseous wiring or plating

–Frontozygomatic suture–Nasofrontal suture–May need extracranial fixation if concurrent mandibular fracture

ƒ Antibiotics

Mandibular Fractures

ƒ Can result in airway obstruction from loss of attachment of base of tongue

ƒ Over 50 % of fractures are multiple

ƒ Condylar fractures associated with ear canal lacerations & high cervical fractures

ƒ High infection potential if any violation of oral mucosa

Mandibular Fracturesƒ Signs and symptoms

–Malocclusion–Decreased jaw range of motion–Trismus–Chin numbness–Ecchymosis in floor of mouth–Palpable step deformity

ƒ Treatment–Prompt fixation : Intermaxillary fixation (arch bars), +/- body wiring or plating

Mandibular fracture

Panorex film showing mandibular fracture

Arch bars and plate used to treat mandibular fracture

Temperomandibular Joint (TMJ) Dislocation

ƒ Can occur from direct blow to mandible

ƒ Also can occur "spontaneously" (from yawning or laughing)

ƒ Mandible dislocates forward & superiorly

ƒ Concurrent masseter & pterygoid spasm

TMJ Dislocationƒ Symptoms

–Patient presents with mouth open & cannot close mouth or talk well–Can be misdiagnosed as psychiatric or dystonic reaction

ƒ Treatment–Manual reduction (place wrapped thumbs on molars & push downward, then backward ; be careful not to get bitten) ; usually does not require sedation or muscle relaxants

ƒ Followup–Soft diet–Pain meds

Nasal Bone Fractures

ƒ Often can be diagnosed clinically and X-rays not needed

ƒ Do not need emergent reduction except to control persistent epistaxis

ƒ Usually do not need antibioticsƒ Early reduction (under local anesthesia) useful if

nares obstructedƒ If nasal septal hematoma : incise & drain, place

anterior pack, antibiotics, and follow-up at 24 hours

ƒ Follow-up timing for recheck or reduction :–Children : 3 to 5 days–Adults : 7 days

Nasal septal hematoma

Simple nasal bridge fracture

Zygomatic Fractures

ƒ Two types :–Tripod (tri-malar) fractureƒ Depression of malar eminenceƒ Fractures at temporal, frontal, and maxillary suture lines

–Isolated arch fractureƒ Less commonƒ Shows best on submental-vertex X-ray viewƒ Mandible movement painfulƒ Usually treat with fixation wire if arch depressed

Tripod Fracture of Zygoma

ƒ Symptoms and signs :–Unilateral epistaxis–Depression of malar prominence–Subcutaneous emphysema–Orbital rim step-off–Relative position of pupils altered–Periorbital ecchymosis–Subconjunctival hemorrhage–Infraorbital hypoesthesia

Supraorbital Fractures

ƒ Frontal sinus fracture–Often associated with intracranial injury–Often show depressed glabellar area–If posterior wall fracture, then dura is torn

ƒ Ethmoid fracture–Results from blow to bridge of nose–Often associated with cribiform plate fracture–Often have CSF leak–Associated or isolated medial canthal ligament injury needs transnasal wiring repair to prevent telecanthus

Orbital Fracturesƒ Can be isolated ("blow out" fracture of

floor) or associated with other major fractures

ƒ Exam to rule out globe injury important–Visual acuity–Visual fields–Extraocular movement (EOM's)–Anterior chamber–Fundus–Fluorescein (to R/O abrasions or assist in finding foreign bodies on conjunctiva)

Traumatic mechanism causing orbital floor fractures

Orbital Fractures

ƒ Symptoms and signs–Diplopia (double vision)–Enophthalmos (sunken eyeball)–Impaired EOM's–Infraorbital hypesthesia–Opacification of maxillary sinus on X-ray–"Hanging drop" in maxillary sinus on X-ray

Interpretation of Diplopia With Orbital Fractures

ƒ With upward gaze (90 %)–Suggests inferior blowout–Entrapment of inferior rectus & inferior oblique

ƒ With lateral gaze (10 %)–Suggests medial fracture–Restriction of medial rectus muscle

Blowout fracture with orbital muscle entrapment

(Which side is the fracture on ?)

Facial film indicating blowout fracture

(On which side ?)

Orbital Fractures : Treatment

ƒ Sometimes extraocular muscle dysfunction can be due to edema and will correct without surgery

ƒ Persistent or high grade muscle entrapment requires surgical repair of orbital floor (bone grafts, Teflon, plating, etc.)

Hyphema (blood in anterior chamber of eye) ; Rx by eye shield, keep patient sitting up, and consult ophthalmology

Ruptured globe with “flat tire” sign

Penetrating Facial Injuries : Additional Diagnostic Studies to Consider

ƒ High or Mid-Facial–Computed tomographyƒ Include cranium as well as face

ƒ Mid or Low Facial–Pharyngoscopy / laryngoscopy–Gastrografin swallow or esophagoscopy (to R/O esophageal injury)

ƒ Any facial level–Angiography

Dental Injuries

ƒ Classify tooth injuries by Ellis category–Ellis Class I : fracture of enamel onlyƒ Treat by filing rough edges–Ellis Class II : involves dentinƒ Refer to dentist (next day)–Ellis Class III : involves pulpƒ Refer to dentist same day

Ellis Class I

Ellis classification of dental fractures

Dental Injuries

ƒ Subluxed (loose) teeth–Should have referral to dentist in < 3 days–Soft diet till seen by dentist

ƒ Avulsed teeth–If root intact, should reimplant as quickly as possible–Chance of success decreases 1 % per each minute the tooth is out of the socket–Do not reimplant primary teeth (will fuse to socket & interfere with permanent teeth)

For deep penetrating facial trauma, angiography may be needed

Facial Soft Tissue Injuries

ƒ Before repair, be sure to rule out injury to :–Facial nerve–Trigeminal nerve–Parotid duct–Lacrimal duct–Medial canthal ligament

ƒ Important to remove (scrub out) any imbedded foreign material in skin to prevent "traumatic tatooing"

Patient with ground-in dirt requiring debridement under anesthesia

Facial Soft Tissue Injuries : General Repair Rules

ƒ For lip lacerations, place first suture at vermillion border

ƒ Never shave an eyebrow (may not grow back)ƒ If debridement of eyebrow laceration needed, debride

parallel to angle of hairs rather than verticallyƒ Put patient on antibiotics for 5 to 7 days for any

intraoral laceration (penicillin VK or erythromycin) and if any exposed ear cartilage (anti-Staph antibiotic)

ƒ Usually remove sutures in 3 to 5 days to prevent cross-marks

ƒ Most bite wounds of the face can be sutured primarilyƒ Clean facial wounds can sometimes be delayed repair

up to 24 hoursƒ Place incisions or debridement lines parallel to the

lines of least skin tension (Lines of Langer)

What 5 major facial injuries does this patient have ?

Facial Trauma Summary

ƒ Assess Trauma ABC's firstƒ Do complete exam as part of secondary

surveyƒ Obtain standard X-rays and / or CT scan

as indicatedƒ Decide if specialist referral and / or

operative repair indicatedƒ Arrange followup after repair to assess

for delayed complications or cosmetic problems