Most common cause of facial injuries includes motor vehicle or motorcycle accident, alteracation, athletic, falls and home accident.
Facial injuries deserve special attention because of their life and aesthetic significant.
Trauma to face is life threathing because of:
Its area of airway passage (mouth and nose)
Its very vascular area (carotid arteries, vertebral arteries)
It may be associated with other injuries to brain and spine.
Facial injuries classified into:
Soft tissue injury.
Both are affected.
Evaluation and initial management:
History: ask about the mechanism of injury and if the patient is unconscious we take the history from witness which includes the mechanism of injury, history of previous medical or surgical disease.
Clinical examination: the examination should be quick and proper.
Begin with overall inspection noting any facial asymmetries, hemorrhage and ecchymosis
Neurological examination of 12 cranial nerves and sensory examination(ophthalmic, maxillary and mandibular)
All bony surfaces are palpated to assess areas of tenderness, crepitation or any bone defect.
Investigation: these include general blood examination e.g.
Hb, PCV, ESR, WBC count.
Also radiological examination which include:
Plain film: which have limited role in the radiological evaluation of facial trauma. Include:
Lateral skull film.
Panorex radiographs for evaluation of mandible.
Submentvertex view for zygomatic arch.
Spinal vertebral X-ray.
B.maxillofacial computer tomography (CT/SCAN): which is study of choice for evaluation of most of facial injuries include axial and coronal.
1. Maintenance of airway: there are many causes of airway obstruction in facial injuries:
Bleeding interferes with respiration.
Displaced facial fractures.
When there is mandibular fracture, the tongue fall back against the pharynx.
Fracture or avulse teeth, vomits, forgien bodies.
Swelling, edema, hematoma narrowing the airway.
Edema tends to develop within 60-90 mints. So patient initially in such case have good airway later it become potentially occluded.
The patient place in prone position, and often assures that there is no cervical spine fracture, the neck is extended.
The obstruction by foreign bodies and avulse teeth can be cleared by sweeping fingers deeply into mouth and oral pharynx.
In some cases intubations may be needed, when there is a difficulty in intubations or in patient with significant neck swelling and fracture mandible are indication of tracheostomy.
2. Control hemorrhage: although hemorrhage from facial wound appears alarming, it seldom to be the sole causes of the shock, except in case of close range shotgun wound.
Hemorrhage can be controlled temporarily by direct pressure.
In rare situation of uncontrolled hemorrhage from nose or nasopharynx angiographic embolization.
3. Aspiration: aspiration of blood, saliva or gastric contents frequently accompanies maxillofacial injury. It prevented by endotracheal Intubations.
4. Shock: shock is only occasional causes by facial injury alone.
Extensive facial injury, penetration ocular injury may cause shock by pain.
When patient with facial injury is found in shock, associated injuries should be suspected.
5. Identification of other injuries: e.g. abdominal or thoracic injuries, intracranial injuries. Cervical spine injuries most injuries to be missed, so patient should be in cautious move and apply cervical collar to patient at site of injury.
In case of injury to cranial nerve in face, anesthesia or parasthesia along the course of nerve indicate fracture proximally. Such as loss of sensation in lower lip indicate fracture mandibular body.
Where as facial nerve palsy indicates injury to facial nerve which could be penetrating wounds of parotid or in case of absences of soft tissue injury may suggest temporal bone fracture.
Soft tissue injuries:
After life threating problem have been resolved, soft tissue injuries are repaired under local or general anesthesia.
Soft tissues injuries can wait without repair up to 24 hours without compromising final result provided the bleeding has been controlled and wound is dressed.
Debridment of wound in face should be conservative.
Soft tissue injuries may include:
Contusion: which is busing injury cause by blunt trauma, can be associated with underlying hematoma.
Abrasion: This is loss of superficial layer of skin.
Puncture: it may be associated with injury of deep structures.
Accident tattoo: in which small dermis embedded particles.
Laceration injury: which most form facial injury and should be repaired in layers.
Avulsion injury: in which there is loss of tissues.
Clean cut injury.
Special region consideration:
1. Cheek and temporal region: high risk of injury to facial nerve and parotid gland.
2. Eyelid injuries: required precise alignment of tarsal plate and lid margin.
3. Lip injuries: align the whitroll and vermilion border first.
4. Eyebrow: should be never shaved and must be repaired with precise attention to its shape and border. Muscles division under brow should always repair to prevent spreading and depression scar.
5. Noses: once the bony framework is accurately restored, soft tissues need only to be approximated According to anatomical arrangement.
Lefort fractures first described by anatomist Rene le fort in 1901.
1. Lefort Ι (transverse fracture): it separated maxillary alveolus at the lower margin of pyriform aperture and extended through maxillary sinus.
2. Lefort ΙΙ (pyramidal fracture): extended from lefort Ι through infrorbital rim and cross the bridge of nose either high or low fashion.
3. Lefort ΙΙΙ (craniofacial disjunction): the fracture line extended across the floor of the orbit and up through nasofrontal area separated the frontal bone from zygoma and orbit.
The neck of condyle is the most common site fallowed by the angle of mandible; the least common site is the region of canine tooth.
Mandibular fracture can be classified according:
1. Region of mandible: condyle and condylar neck, ramus, coronoid, angle, body, symphysis.
2. Open or closed: depending on whether or not have communication with skin laceration.
3. according to direction: whether oblique, transverse, comminuted.
Usually patient presented with pain, swelling, tenderness and malocclusion. Also numbness in distribution of mental nereve, bleeding from laceration or from socket of tooth, trismus (pain on moving the jaw) is noted
On palpation we can feel crepitus, tenderness and when patient to open his or her mouth ask, the jaw deviated toward one side.
Radiographic evaluation of mandible consists of plain film, CT/SCAN, Panorex examination.
May result in disarticulation of zygomatictemporal and zygomaticomaxillary sutures lines.
Infraorbital nerve parasthesia.
Tenderness and brusisng.
In case of isolated zygomatic arch fractures there will be limitation of mandibular range of motion.
Bony orbit fractures:
Inferior and medial wall are most frequently involved usually patient presented with diplopia due to injury of muscles or nerve,and also presented with subconjectival hemorrhage. patient could presented with enopthalmus i.e. inward movement of eye globe due to pressure from outside or patient could presented with exopthalmus which indicated retrorbital hematoma.
Nasal bone fractures:
Nasal fractures are either laterally or posteriorly displace.
Symptoms and signs:
Swelling over the external surface of the nose with swelling in the medial orbital region.
Pain, respiratory obstruction.
Crepitation, nasal deformity, septum deviation.
Nasal bleedings (epistaxsis)
Mucosal laceration presented with hematoma.
Radiographic examination is not absolutely indicated and usually need to exclude other injuries.
Septal hematoma should be drainage surgically because it causes dissolution of the cartilage because of pressure necrosis.
Corticosteroids are used to minimize edema and facilitated evaluation of fracture reduction.
epistaxsis can be arrest by:
Raise head up.
Pressure on nose externally.
Or by internal pressure by gauze with Vaseline.
4. Management of fractures should done immediately before a significant edema is developed or after edema is resolve usually after 5-7 days during this period the patient should give steroid and antibiotics.
Management of fractures by refracturing the bone and reposition of nasal bone in proper architecture, and with used of internal packs with jipsona used externally to hold the bone.
Internal packs are removed in day 3, while external jipsona are removed in 12 days.