- those with facial injuries have a high chance of having other serious injuries:
(2) airway obstruction
(3) pulmonary contusion
- mostly blunt
- no airbags
TYPES OF INJURY
- mandibular #
- mid-facial # (Le Fort I -> III #)
- TMJ disruption
- zygomatic, orbital and nasal #
- soft tissue injuries
- associated injuries: BOS #, TBI, cervical spine #, carotid injury
- fractures at the vunerable points (ramus, body at level of 1st and 2nd molar)
- bilateral # can precipitate airway obstruction from posterior displacement of tongue
- 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.
- mechanical impairment may result from condylar or zygomatic arch fracture and can prevent jaw opening (even when paralyzed).
- 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)
- 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 #)
- carotido-cavernous fistula (pulsatile exopthalmos, orbital bruit)
- cervical spinal injury
- traumatic occlusion or dissection of internal carotid artery or vetebral artery
- thoracic trauma
- abdominal trauma
- assess and secure airway (may require cricothyroidotomy/tracheostomy)
- stop bleeding (nasal tampons)
- 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.
- 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
- 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. Review. PubMed PMID: 16988311; PubMed Central PMCID: 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. doi: 10.1055/s-0030-1269764. PubMed PMID: 22550459; PubMed Central PMCID: 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. Review. PubMed 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. Epub 2005 Mar 24. Review. PubMed 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. doi: 10.1016/j.ijom.2007.11.003. Epub 2008 Feb 21. Review. PubMed 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. doi: 10.1016/j.ijom.2007.11.002. Epub 2008 Jan 18. Review. PubMed 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. doi: 10.1016/j.ijom.2007.11.005. Epub 2008 Feb 11. Review. PubMed 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. doi: 10.1016/j.ijom.2007.11.004. Epub 2008 Mar 4. Review. PubMed PMID: 18295453.
FOAM and web resources
- EMCrit Podcast 112 – Exsanguinating Hemorrhage from Mid-Face Fractures (2013)