Facial trauma introduction

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Up to 60% of facial trauma patients have associated injuries

20-50% brain injury

1-4% C spine injury

0.5-3% blindness (most commonly with Lefort II and III)

Remember spouse abuse (most common injury is to orbital rim) and child abuse

25% of patients with facial trauma will go on to develop PTSD


High impact Low impact

Supraorbital rim 200G (multiples of gravity) Zygoma 50G

Symphisis of mandible 100G Nasal bone 30G

Angle of mandible 70G

Frontal Bone 100G

Key concept is to manage airway and look for associated injuries

AIRWAY (most important part of management)

Look, listen and feel

Chin lift, jaw thrust

Suctioningand remove FB

Manually displace tongue forward. Consider OPA

Maintain C spine immobilization

Avoid nasotracheal intubation because of possible cribriform plate fracture

Use RSI cautiously b/c might be a difficult airway

Consider awake intubation with ketamine or fibreoptic intubation

Don’t be a hero- call for backup, prepare for cricothyroidotomy


Facial bleeding should not cause shock or hypovolemia – look for another source

3 areas that bleed:

Maxillofacial bleeding: control with direct pressure, don’t blind clamp

Nasal bleeding: consider anterior or posterior packing

Pharygneal bleeding: pack around the ET tube


Same as a general trauma history

Specific questions for facial trauma

Is there pain with eye movement? injury to the globe, orbital bones

Are there areas of numbness or tingling on your face?-nerve entrap or laceration

Is the patient able to bite down without any pain?

Is there pain with moving the jaw?- fracture or impingement

Bird’s eye view and Worm’s eye view

Palpate supra and infraorbital rims

Globe: enopthalmus or exothalmus, abnormal shape of pupil, subconjunctival hemorrhage, visual acuity

Check cornea for abrasions, anterior chamber for hyphema

Fundoscopy to assess retina

Lids- look for lac. Injuries to medial 1/3 may involve lacrimal apparatus

Palpate the medial orbit area to r/o naso ethmoidal orbital fx. (Q tip inside the nose directed towards the medial canthus, place your finger outside the medial canthus. If the bone moves NEO #.)

Palpate zygomaticofrontal suture, zygomaticotemporal suture and arch

Palpate nose: asymmetry, widening of nasal bridge (telecanthus- normal intercathi distance is 32-34mm), septal hematoma, blood, deformity, crepitus, subq air and CSF – halo sign on paper towel

Palpate maxilla for facial instability/mobility

Palpate mandible for tenderness, swelling and step off

Cranial nerve exam- most important- EOM and facial nerve

Intraoral exam:

Inspect the teeth for malocclusions, bleeding and step-off.

Must account for all teeth.

Manipulate each tooth, check for gum lacerations,

Tongue blade test. (twist tongue blade while pt bites down. If jaw broke, pt will open mouth) 95% sens and 65% spec.

Palpate the mandible for deformities, step-offs, tender areas

Xrays are useful for assessment of:

Bones, fluid-filled spaces, herniation of orbital contents, subQ air

Basic Facial Series

1)Water’s: (occipitomental view): Single best xray, good screening view for maxillary #. 37o caudal to canthomeatal line- good to see superior and inferior orbital rims, nasal bones zygoma and maxilla

2) Caldwell view (PA or occipitofrontal view): 15o caudal to canthomeatal line - frontal sinus and supraorbital rim

3)Lateral view – anterior wall of frontal sinus and maxillary sinus views

4)Submentovertex view:occasionally done. Good for zygomatic arch

Jaw series: 1) PA, 2) lateral obliques, 3) Towne’s view and 4) panorex ( best view of mandible)

CT face

Better than Xray; gold standard for facial fractures

Indicated if

# suspected on exam

Can’t cooperate well for x-ray

Penetrating injury


Palpate along frontal bone and supraorbital rim for deformity or subq air

Associated with dural tears, intracranial injury and injury to orbital roof

MUST evaluate posterior wall of sinus with CT

Non displaced anterior wall: abx, should still consult neursurg for outpatient followup

Depressed anterior wall or posterior wall fractures- assume to have assoc dural tear


Neurosurg consultation

Abx and tetanus

Complications of posterior wall fracture: mucocele, CSF leak, epidural empyema, meningitis, associated orbital fracture


High force mechanism, consider associated injuries

LeFort Classification (rarely isolated, most commonly occur in combination)

LeFort I - maxilla at level of nasal fossa

Maxilla mobile, nasal bridge stable

Malocclusion of teeth

LeFort II - maxilla, nasal bones, medial aspect of orbits (pyramidal dysfn)

nose and upper jaw mobile on exam

LeFort III - maxilla, zygoma, nasal bones, ethmoid,

vomer, cranial base (craniofacial dysfunction)

dish face deformity ( elongation of eyes with flat sunken face) At risk for airway obstruction

Management : plastics consult for OR

Airway is most important: ETT –> cric

Rhinorrhea uncommon with I, more common with LF II/III

admit for abx prophylaxis (not proven)

and elevation of head of bed 40-60% if C spine cleared

2nd MC facial #

Two types: arch and tripod

Arch fracture

Pain over arch +/- bony deformity

Pain with opening mouth or impingement of temporalis muscle/coronoid process

Look for flattened cheek

Submental view (bucket handle view)

Management: refer for outpt ORIF

Tripod fracture

Fracture through 1) arch (or zygomaticotemporal suture) 2) zygomaticofrontal suture 3) infraorbital rim and floor

Presents with flat cheek, infraorbital nerve damage (anesthesia), diplopia, change in consensual gaze, step defect, globe injury

Water’s is best Xray but you should CT face

Refer for ORIF (may be outpt if non displaced and without eye involvement)


Suspect if trauma to nose or medial orbit

Pain with EOM

Associated lacriminal disruption and dural tears

Look for flat or saddle shaped nasal bridge, telecanthus, epistaxis or CSF rhinorhea

Q tip test

Needs CT

Consult plastics


Can be isolated or combined (commonly with zygomatic #)

Blow out fracture: force transmitted to thin orbital floor (or medially)

Direct globe pressure from object < 5 cm radius.

Also from direct blow to infraorbital rim that causes orbital floor to buckle

Possible herniation of fat or muscle into maxillary sinus (tear drop sign)


Step off of infraorbital rim

Diplopia due to muscle/fat entrapment, intramuscular hematoma, V2 neuropraxia

True entrapment will be vagal, vomiting, refuse to move eye

Enopthalmos (sunken eye) and limited EOM (limited upward gaze)

Infraorbital anesthesia

Orbital emphysema

Should have a CT but on xray look for

Tear drop sign (herniated fat into maxillary sinus)

Open bomb bay sign (bony fragments protrude into maxillary sinus)

Air fluid level in sinus


Refer to plastics and ophthalmology

Tetanus and abx

Avoid valsalva

Decongestant for 3 days

Most observe for 10 - 14d then decide on OR based on enopthalmos/diplopia

Orbital emphysema

May present with visual acuity loss b/c of pressure on orbit causing central

retinal artery occlusion

Emergent decompression with needle or canthotomy w/ cantholysis

MC facial # - 3 kinds: nondisplaced, depressed and laterally displaced

Ask pt if they have broken nose before, how is your breathing, does it look normal

Crepitus, deformity, swelling, tenderness, edema

Epistaxis usually mild but can be heavy

Clinical dx: NO Xrays although can sometimes see on facial lateral xray


Pack bleeding

R/o septal hematoma: drain, pack, ENT follow up if present

Immediate reduction: can do if full edema not yet dev’t (within 3 hours)

Delayed reduction: if already dev full edema- refer for reduction in 6-10 days

If you choose to reduce- intranasal cocaine, bilateral infraorbital nerve blocks and bilateral external nasal nerve. Use boies elevator or scalpel handle to elevate depressed bone and forceps to reduce deviated septum

Peds: do not reduce, refer for evaluation in 4/7

Consider assoc injuries: Bridge of nose: nasoethmoid # -----> rhinorrhea, CT face, abx, neurosurg consult


Mandibular pain/tenderness, malocclusion, separation of teeth, periauricular pain

Trauma + malocclusion = mandibular #

Ecchymosis on floor of mouth very suggestive

Multiple locations in > 50%; may be distant from site of trauma


Condylar 35%

Body 21%

Angle 20%

Symphysis 14%

Ramus 3%

Coronoid 3%

Panorex view best

CT may be needed for condylar #

Non-displaced: soft diet, analgesic, orif in 1-2 days

Displaced and open #’s are closed sooner

Antibiotics if open: usually penicillin



Weak TMJ

Shallow articular eminence

Overstretched joint capsule

Neuromuscular disorders

Trauma to jaw

Excessive mouth opening

Mostly anterior but posterior (direct blow to chin), lateral (associated with fracture) and superior can occur

Mostly bilateral

For anterior: jaw will jut out forward and will deviate away from dislocated side if unilateral

Muscles of mastication spasm preventing spontaneous reduction

X-ray if mechanism suggests potential #

To reduce: Thumbs or fingers in buccal sulcus or wrapped in gauze on mandibular teeth

Downward backward pressure with rotation so chin goes upward and angle of mandible goes backcward

May be easier to reduce one side at a time

D/C home with soft diet x 2wks and outpatient F/U with oral surgery

:mandible reduction.jpg


Don’t forget tetanus

May close facial lacerations up to 24hrs

Indications for delayed primary closure

Wound older than 24 hrs

FB that can’t be removed

Severe contamination can close early if thoroughly debride but if > 6 hours, should treat with abx for 4 days and then close

Presence of # requiring further evaluation/therapy

When to consult plastics?

Uncomfortable w/ lac

Underlying nerve injury

Injury requiring OR

Delayed primary closure

Wound Management

Avoid epi in ear, nose, tarsal plate of eyelid

Regional blocks, LAT useful

Vigorous scrubbing for abrasions to prevent traumatic tattooing

Careful exploration for FB

Copious, forceful irrigation

Deep: 4-0, 5-0 vicryl

Skin: 5-0, 6-0 prolene/ethilon

No drsg, polysporin, remove 3-5d (minimizes scar)

Indications for antibiotics in facial injuries

Bite wounds


Through-and-through buccal mucosa

Cartilage involvement (nose/ear)

Extensive contamination

Always consider nerve blocks


Close vermillion border first


Close big lacs and flaps, midline lacs, avulsions, nonlinear lacerations

Oral cavity

Refer if salivary ducts involved


Auricular nerve block

Approximate cartilage with 5-0, 6-0 absorbable;

Staph abx coverage b/c avascularity of cartilage is high risk for condritis

Subperichondral hematoma: will develop “cauliflower” ear if not drained;

aspirate and compressive dressing for 7d with close f/u and repeat aspiration prn


Refer to optho: lid margin and medial canthus lacs

Through-and-through cheek

Begin intraoral and work outwards

Copious irrigateion after each layer closed

Abx prophylaxis


Plastics for lid margin, canalicular, lacrimal

6-0 Ethilon for superficial lacs
Retro orbital hematoma

-proptosis, decreased visual acuity, IOP > 40, afferent papillary defect

Management: time is EYE therefore pt needs lateral canthontomy

Lateral canthotomy steps:

Local anesthesia and sedation

Crimp skin downward from lateral eye with kellys to reduce bleeding x 1 minute

Cut the skin (canthotomy)

Lift inferior skin flap to identify tendon (tendon feels like guitar string)

Cut the tendon (cantholysis)

Goal IOP < 40

Repeat same steps for superior lateral canthal tendon
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