Those with facial injuries have a high chance of having other serious injuries



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Facial Trauma

18/4/11


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- those with facial injuries have a high chance of having other serious injuries:


(1) TBI

(2) airway obstruction

(3) pulmonary contusion

(4) aspiration


- mostly blunt

Risk factors
- MVA

- non-restrained

- no airbags

- ET-OH


TYPES OF INJURY
- mandibular #

- mid-facial # (Le Fort I -> III #)

- TMJ disruption

- zygomatic, orbital and nasal #

- soft tissue injuries

- haemorrhage

- associated injuries: BOS #, TBI, cervical spine #, carotid injury

MANDIBULAR #


- fractures at the vunerable points (ramus, body at level of 1st and 2nd molar)

- bilateral # can precipitate airway obstruction from posterior displacement of tongue



MIDFACE #
- 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.

TEMPROMANDIBULAR JOINT
- mechanical impairment may result from condylar or zygomatic arch # and can prevent jaw opening (even when paralyzed).

ORBITAL #’s


- severity can vary

- oedema and ecchymosis -> subconjunctival haemorrhage and loss of vision -> ocular rupture.

- blow out # = when pressure directly applied to eye with fracture of inferior bony structures (enophthalmos, diplopia, impaired eye movement, infraorbital hypoesthesia)

NASAL #’S


- prime concerns = epistaxis and septal haematoma.

SOFT TISSUE INJURIES


- abrasions, contusions, lacerations.

- evolving oedema over 24-48 hours can be massive -> consider airway patency.

ASSOCIATED INJURIES TO BE AWARE OF
- Base of skull #

- CSF rhinorrhoea (anterior or middle fossa BOS #)

- carotido-cavernous fistula (pulsatile exopthalmos, orbital bruit)

- TBI


- cervical spinal injury

- traumatic occlusion of internal carotid artery

- thoracic trauma

- abdominal trauma


MANAGEMENT


Resuscitate
- assess and secure airway (may require cricothyroidotomy/tracheostomy)

- stop bleeding (nasal tampons)


Specific
- open, contaminated wounds: irrigation, debridement, removal of foreign bodies and closure within 24 hours.

- early surgery if orbital injury with optic nerve compression is present.

- tetanus

- prophylactic antibiotics for CSF leak: controversial



- internal fixation @ 4-10 days to allow swelling to subside


Jeremy Fernando (2011)



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