facial trauma

see also:

• trauma
• faciomaxillary

• consider possibility of non-accidental injury in young children with facial trauma

• 4 main aetiologies:
  • ruptured ear drum from barotrauma from blunt impact onto ear
  • penetrating injury causing laceration to ear canal or ruptured tympanum
  • # base of skull - may have other features such as racoon eyes, etc.
  • # ear canal from fall onto chin and mandibular condyles impacting ear canal

• very common
• fall from standing height or higher onto chin
• hit by blunt object (eg. fist, elbow, knee, ball)
• major trauma

• very common, 40% of all facial fractures
• fall from standing height or higher onto face (“face-plant”) - in elderly, these are also associated with C2 spine fractures
• hit by blunt object (eg. fist, elbow, knee, ball)
• major trauma

• common 6-25% of facial fractures
• major trauma such as road trauma, falls from a height > 3m
• of non-major trauma patients:
  • ~60% assaults
  • ~20% sports injuries eg. fist, elbow or knee to cheek/eye
  • ~15% moving / running at speed into an object
  • <5% are due to falls from standing height, and if they are, they tend to be intoxicated people falling onto a hard blunt object
  • NB. it is rare for a seizure at standing height to result in fracture maxilla or orbit unless unlucky to strike a hard blunt object (see below)
• by injury mechanism:
  • orbital blowout fracture
    • hydraulic pressure of impact of a ball-like object (eg. fist, ball) hitting the orbit fracturing inferior wall of orbit
  • isolated direct injuries:
    • direct blow from a small object (eg. hammer)
  • upward submental force injuries (eg. fall onto chin)
    • may cause vertical fractures through alveolar ridge, infraorbital rim, and zygomatic arches
  • Le Fort 1 injuries:
    • downward force low on alveolar rim of maxilla (ie. just above the upper teeth roots)
  • Le Fort II injuries:
    • force to the lower or mid maxilla
  • Le Fort III injuries:
    • force to the nasal bridge or upper maxilla

• injuries to the teeth and jaw including TMJ dislocations in particular, are more common in those with epilepsy than the general population however, it appears rare for a patient with a seizure and no major trauma (eg. fall from height or motor vehicle accident) to sustain a fractured orbit or maxilla ¹⁾
• unpublished retrospective audit of patients showed ²⁾:
  • those with fractured orbit or maxilla did not reveal that seizures were a significant cause, although some 2% resulted from drunk patients falling over onto hard objects
  • those presenting with seizures at standing height or less, rarely if ever sustained a fracture maxilla or orbit

• see also: Airway assessment and management - maxillofacial trauma considerations

• post/inf. displaced fractured maxilla occluding nasal airway:
  • disimpact by pulling maxilla forward
• tongue may lose its ant. insertion in pts with bilateral ant. mandibular #s causing it to block oropharynx:
  • insert 0 silk deep traction suture into dorsum of tongue transversely
• teeth, dentures, bone fragments, vomitus, haematoma, foreign bodies may obstruct airway
• haemorrhage:
  • from oropharynx:
    • apply compressive gauze pads to bleeding points
  • from nose:
    • #s of middle third face are usually bilat. with disruption of nasal septum, thus haemorrhage from one side manifests equally at both nostrils
    • exclude possibility of bleeding from basilar # by palpating pharyngeal wall for tears & fractures
    • insert ant. & post. nasal packs
• soft tissue swelling & oedema
• trauma to larynx or trachea
  • maintain high index of suspicion if mechanism of injury or S/S suggests trauma to larynx/trachea:
    • blunt trauma to neck (eg. steering wheel)
    • neck swelling, SOB, voice alteration, frothy haemorrhage
    • surgical emphysema, tenderness, laryngeal or tracheal crepitus
  • lat. & AP soft tissue Xrays of neck & mediastinum looking for s/c emphysema
  • consider bronchoscopy to determine site of injury

• control any ongoing bleeding by (esp. check scalp & puncture wounds):
  • direct compression bandage
• regular assessment of wounds for blood loss & if continues then:
  • explore wounds (if puncture wound, extend wound along natural crease lines)
    • ligate or clip bleeding vessels
  • if profuse bleeding from a neck wound:
    • consider whether there is enough time for arteriography
    • check arm pulses
    • extend the wound to expose major vessels in the neck (usually along ant. border sternocleidomastoid)
      • control the bleeding & assess damage
      • small vessels off the ext. carotid may be ligated
      • large arteries (eg. carotis/subclavian) usually require repair
      • it is possible to ligate one int. jugular V without untoward effect
      • it may be possible to ligate one common carotid artery without causing stroke
• expose affected area by cleaning all wounds, face & scalp with N saline
• do not discard any loose bone or soft tissue fragments
• examine scalp, esp. occiput remembering to maintain Cx spine protection if needed
• examine eyes for:
  • visual acuity - count fingers, read print:
  • direct trauma to globe
  • secondary vision loss over the next 24-48hrs may be due to orbital emphysema or acute retrobulbar haemorrhage both of which need urgent decompression to prevent permanent blindness due to pressure on the optic nerve, central retinal artery occlusion or compression of optic nerve vasculature.
  • limitation of movements, diplopia, unequal pupillary levels:
    • suspect trauma of orbital floor & wall with entrapment of periorbital tissues
  • direct, consensual & accommodation reflexes:
    • may help detect rise in intracranial pressure, but false pos. if trauma to globe producing post-traumatic mydriasis & retrobulbar h'age
  • proptosis:
    • suggests haemorrhage within orbital walls - acute retrobulbar haemorrhage needs urgent decompression
  • enophthalmos:
    • suggests fracture of an orbital wall - usually floor or medial
  • periorbital swelling:
    • suspect # zygoma or maxilla
  • subconjunctival ecchymosis:
    • suspect direct trauma to globe or # zygoma
  • ant. chamber & fundus for evidence of direct trauma or raised ICP
• examine nose for:
  • deformity, pain, mobility & difficulty in breathing
    • if suspected fractured nose:
      • examine to exclude septal haematoma (unlike deviated septum, the swelling is indentable on applying pressure)
        • if severe blow, nose should be re-examined in 48hrs to exclude development of haematoma which may present as fever, pain & nasal obstruction.
        • if not evacuated early, it will become infected leading to necrosis of septal cartilage & collapse of nasal bridge which will require extensive corrective surgery, thus contact senior doctor or ENT if in doubt.
      • Xray of nose is of NO use, don't ask for one
      • if there is clinical swelling/deformity, ensure early plastics review (within 5 days).
        • consider early reduction of displaced nasal fractures:
          • how to reduce a fractured nose under local anaesthesia
  • bleeding & CSF leak
    • do not pass nasal ETT or NGT
  • measure intercanthal distance:
    • if > 3.5cm suspect nasoethmoid fracture
• examine ears for bleeding, haemotympanum & CSF leak:
  • bleed from ant. wall of ext.aud. meatus suggests # condylar neck of mandible
  • bleed from post. wall of ext.aud. meatus or middle ear suggests basilar # in middle cranial fossa
  • ecchymosis behind ear (Battle's sign) suggests basilar # in middle cranial fossa
• examine soft tissues for:
  • trigeminal nerve sensation
  • facial nerve motor incl. orbicularis oculi as branch may be involved in # zygoma
  • surgical emphysema around eyes & on face:
    • suggests continuity between sinuses & face due to facial #
    • instruct pts not to blow nose
    • exclude causes in neck/thorax
  • venous engorgement of face:
    • suspect trauma of major vessels in thorax or neck
  • pooling of tears & leakage from eye:
    • suspect injury to lacrimal apparatus
  • leakage of pink or clear fluid from a facial wound or blood from Stenson's duct:
    • suspect damage to parotid duct
      • anatomic marking: line from bottom of tragus to upper border upper lip
      • if parotid gland pentrated but duct intact, then simple layered closure adequate
      • if duct is injured then specialist Sx as need careful repair over a stent
• wounds:
  • probe all for glass & Xray to exclude embedded glass
  • irrigate well & exclude injury to underlying structures that may need repair
  • close with 6/0 nylon if dermal (consider 5/0 in older pts with tougher skin) - remove on day5 then steristrip
• abrasions:
  • careful scrubbing to remove dirt & prevent traumatic tatooing
  • warn of risk of pebbly texture due to small irretrievable pieces of glass & scar tissue formation, & refer to plastic Sx OP for F/U
• examine the face for lengthening, bilateral swelling, “panda eyes”, or dish face deformity
  • suspect bilateral maxillary #
• palpate around orbit for step defects, esp. at frontozygomatic & zygomaticomaxillary sutures
  • indicate # zygoma or maxilla
• palpate mandible externally from condyle & along lower border for tenderness, step defects & crepitus
• examine intraorally for:
  • haematoma:
    • esp. under tongue where suggestive of mandibular #
  • lacerations/bleeding
  • loose/broken teeth & dentures
  • mobile jaw segments
  • abnormal alignment of jaw & step defects, & teeth meeting prematurely
• using both hands, palpate middle third of face for mobility by gentle forward pressure
• discuss with radiologist which views are appropriate:
  • consider OPG
  • AP occipitomental Xray:
    • check along the 3 standard arcs (supraorbital, infraorbital & floor max.sinuses) for fractures

• this is an ophthalmic emergency requiring prompt recognition and immediate decompression.
• clinical features:
  • secondary visual loss usually with painful proptosis or exophthalmos
  • +/- peri-orbital oedema, bruising and an afferent pupillary defect and raised intraocular pressure
• DDx of traumatic visual loss after blunt trauma:
  • retinal detachment
  • hyphaema
  • globe rupture
  • vitreous haemorrhage
• Ix: CT scan or bedside ocular US
• Rx: 
  • immediate decompression (lateral canthotomy +/- inferior cantholysis) - avoid wasting time waiting for a CT scan report
  • avoid eye patches as they may delay diagnosis and may increase IOP
  • IV mannitol 20% 2g/kg 6h
  • IV acetazolamide 250mg 6h
  • IV methylprednisolone 250mg 6h
  • topical timolol 0.25% i-ii drops bd

• high-velocity MVA
• massive soft tissue injury & swelling
• midface mobility
• malocclusion
• CSF rhinorrhoea - rare in LeFort I but often seen in LeFort II/III

• Plain XRay:
  • Water's view
  • views of lateral facial bones
• CT may be helpful in further elucidation of extent & number of #s

• I: involves only the maxilla at the level of the nasal fossa
• II: involves maxilla, nasal bones & medial aspects of orbit ⇒ pyramidal dysfunction
• III: involves maxilla, zygoma, nasal bones, ethmoids, vomer & all lesser bones of cranial base ⇒ craniofacial dysfunction
• LeFort #s rarely occur in pure form but usually one level on one side & another on other side

• airway support - may need intubation or cricothyroidotomy
• bleeding control - ant/post. nasal packing if doesn't cease spontaneously +/- Sx
• refer to facio-maxillary Sx as practically all pts require wiring & plating via intraoral, infraorbital, zygomatico-frontal & bicoronal approaches
• optimum timing varies from immediate to 5-7 days when swelling has subsided
• if open skull fracture present (CSF rhinorrhea or if i/cranial air seen on Xray):
  • elevate head 40-60deg. if possible
  • ? prophylactic antibiotics - eg. ceftriaxone or Keflin/Flagyl
• if persistent leak, it can be localised by i/thecal injection of metrizamide then CT head

• zygoma has 2 major components: body or malar eminence and the arch

• trimalar or tripod #:
  • depression of malar eminence with # lines usually at:
    • zygomaticotemporal suture
    • zygomaticofrontal suture
    • through the infraorbital foramen
  • may produce flatness of cheek, infraorbital N paraethesiae, diplopia or step defect
• depression of zygomatic arch:
  • may produce palpable bony defect over arch, limited or painful mandibular movement due to interference with movement of coronoid process of mandible

• plain XRays:
  • Water's view for malar eminence
  • submental-vertex view for arch

• analgesia
• plastic Sx OP F/U within 1wk for delayed elevation at 5-7 days of #
• most can be elevated via a Gillies temporal approach
• some require plating at the infraorbital or zygomaticofrontal suture
• post-op eye obs for early detection of retrobulbar haemorrhage (rare):
• if proptosis or blurred vision occurs then:
  • dexamethasone
  • mannitol
  • urgent ophthalmology consult
• advise not to blow nose as risk of emphysema

• may be isolated or accompany an orbital wall # (eg. zygoma #)

• transmission of force hydraulically to floor of orbit when object with radius of curvature < 5cm hits orbit
• may produce enophthalmos, impaired ocular mobility esp. on upward gaze, diplopia, infraorbital N paraesthesiae
• Ix:
  • plain XR:
  • maxillary sinus view may show:
    • “hanging drop” sign of herniated contents
    • depression of bony fragments into maxillary sinus
    • emphysema of orbit (may cause loss of vision - an ocular emergency!!)
    • clouding of sinus on side of trauma must be assumed to be # orbit until proven otherwise
  • CT
• Mx: analgesia, plastic Sx OP F/U 1wk for repair if not resolved (impaired mobility may be just oedema)

• most common site injured
• gross deformity may be reduced in ED with lateral pressure
• XRays are not of benefit
• exclude septal haematoma as untreated may result in sepsis & septal necrosis
• F/U in plastic Sx OP in 4 days for children & 5-7 days for adults so assessment can be made once swelling has resolved, reduction is ideally performed within 1 wk.

• #'s of nasal bones, frontal process of maxilla & medial orbital walls
  • ⇒ dished in face & traumatic telecanthus
• NB. normal distance for inner canthus is 28-33mm
• Ix. CT scan is best
• Mx:
  • open reduction via local incisions or a bicoronal approach
  • canthoplexy to correct telecanthus

• 3rd most common facial fracture after nasal & zygomatic

• mandibular pain, tenderness
• malocclusion
• step-off in dentition
• ecchymosis in floor of mouth

• 36% condyle
• 21% body
• 20% angle
• 14% symphysis
• 3% coronoid process
• 3% ramus

• OPG (orthopantomogram) is imaging of choice:
  • may not detect condylar #s - may need coronal CT view
• if OPG unavailable, then lat. & AP views may suffice
• reverse Townes view is good for condylar regions
• NB. always look for 2nd or 3rd # site - the contre-coup injury

• usually require admission & occlusion fixation preferably within 24hrs
• i/oral plating
• mandibular wiring if too many teeth missing
• consider antibiotics:
  • if compound:
    • bleeding around teeth or obvious bony fragments
    • # extending through teeth bearing portion
  • cephalexin + metronidazole

• see also: temporomandibibular joint disorders
• may be post-traumatic or simply by yawning
• pt has open mouth & cannot be closed, & is in moderate discomfort
• mandible dislocates forward then superiorly, with spasm of jaw muscles preventing condyles from returning to their normal position
• maybe unilateral or bilateral
• exclude buccolingual phenothiazine reaction
• if traumatic, XRay to exclude #s

• wrap your gloved thumbs in gauze for protection & place them on 3rd molars of mandible with fingers curled under symphysis
• downward pressure is then exerted on the molars, with slight upward pressure on symphysis to lever condyles downward
• slight post. pressure is then applied to achieve reduction
• may need to ise IV midazolam to facilitate reduction
• take post-reduction Xrays if this is 1st dislocation for the pt
• if significant pain, tenderness or spasm persists then admission & occlusal fixation should be considered, otherwise discharge on NSAID with advice to adhere to soft diet for several days & avoid yawning or otherwise stressing the TM ligts.

• see dental
• Rx depends on level of injury:
  • enamel layer only:
    • uniform tooth color
    • Rx - may need smoothing of rough edges of enamel
  • enamel & dentin:
    • presence of yellow dentin
    • Rx: application of calcium hydroxide & cover with aluminium foil with dental R/V in 24hrs
  • dental pulp:
    • pink or red pulp
    • immediate dental referral to avoid abscess formation
  • avulsion of tooth:
    • transportation of tooth:
      • under tongue
      • in milk, saline or wet handkerchief
      • do not touch or wipe root!! - handle by crown only
    • re-implantation:
      • rinse tooth with Nsaline if possible
      • insert into socket as soon as possible (only 5% teeth survive if > 2hrs out of socket)
      • splint tooth in place:
        • Histoacryl glue applied externally across gum margin
        • acrylic splint
    • if tooth cannot be found then CXR to exclude aspiration
  • all pts with dental trauma should be advised that any teeth involved may later die & require root canal Rx

• may follow severe blow to head
• it is imperative to check if post. wall is fractured (eg. lateral tomograms or CT)
  • this suggests dural tear ⇒ admit & place in head up position
• ant. wall # will require elevation as outpatient
• prophylactic antibiotics should be given