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Facial TraumaBabak Saedi MDOtolaryngologist
Tehran University of Medical Sciences
The External Bony Facial Skeleton
Composed mainly of the frontal bone, temporal bones, nasal bone, zygomas, maxilla, and mandible.
Ethmoid, lacrimal, sphenoid bones contribute to inner portion of orbits
Upper third - above superior orbital rim Middle third (midface)- superior orbital
rim down through maxillary teeth Lower third - mandible
Bones of the Facial Skeleton
Maxillofacial Trauma
Maxillofacial Trauma
Patient evaluation
Patient Evaluation
History
Physical exam
Other systems: - Airway - Circulation - CNS (GCS)
Physical examination
Orbit
Nasal airway
Dental occlusion
Neurovascular
Soft tissue damage
Contusion
Avulsion
Laceration
(loss of soft tissue – penetrating
trauma)
Physical Examination
First, inspect face for deformity and asymmetry
Enophthalmos, proptosis, ocular integrity, ocular movements
Nasal septum for position, integrity, and presence of septal hematoma
Epistaxis or CSF rhinorrhea
Physical Examination
Complete neurological exam must be performed on any patient with suspected facial trauma
Sensation - test all 3 major branches of the trigeminal nerve
Motor function - assess facial nerve by having patient wrinkle forehead, smile, bare teeth, and close eyes tightly
Physical Examination
Palpation of facial structures - the infraorbital and supraorbital ridges, zygoma, nasal bones, lower maxilla, and mandible
Assess for tenderness, bony deformities, crepitus, . . .
Malocclusion or step-off in dentition may be sign of mandibular fracture
Diagnostic Imaging
Should focus on bony integrity, fluid-filled sinuses, herniation of orbital contents, and subcutaneous air
Overall status of the patient, physical exam findings, and the clinician’s initial impression determine timing and nature of imaging ordered
Plain films
Traditionally the mainstay in the radiographic evaluation of facial trauma
Standard plain film facial series: Waters (occipitomental), Caldwell (occipitofrontal), and lateral views
Panoramic films are used to best evaluate mandibular fractures
CT scan
Offers a viable, cost-effective alternative
to plain films
Very helpful in the evaluation of facial
trauma when facial edema, lacerations,
other injuries, or altered level of
consciousness limit usefulness of clinical
exam
MRI
Limited role of MR in evaluation of facial trauma due to insensitivity of MR to fractures
Used to provide complimentary information to CT in the evaluation of the eye and its associated structures
Nasal bone
Nasal Fractures
Most common site of facial trauma due to location
May be displaced medialy, laterally or posteriorly
Requires control of epistaxis and drainage of septal hematoma, if present
Nasal fractures - classification
Class 1 - frontal or frontolateral trauma
- vertical septal fracture
- depressed or displaced distal part of nasal bones
Class 2 - lateral trauma
- horizontal or C-shaped septal fracture
- bony or cartilaginous septum fracture
- frontal process of maxilla fracture
Nasal fractures - classification
Class 3 - high velocity trauma- fracture extends to ethmoid
labyrinth- bony septum rotates
posteriorly- bridge collapse- upturned tip, revealing
nostrils- depressed nasal bones
pushed up under frontal bones- apparent inter-ocular space
widening
Nasal fracture
Diagnosis: - physical exam (asymmetry,
deviation, epistaxis, swelling, . . .) Radiography: - do not have a role in management Timing: - before 10 days to 2 weeks - within two hours after injury
Nasal fracture
Managements: (closed & open reduction)
Complications: - septal hematoma - CSF leakage - ophthalmologic compl.
Septal haematoma
closed reduction
Zygomatic Fractures
Tripod fracture: zygomaticofrontal suture, zygomaticotemporal suture, and infraorbital foramen
Present with flatness of the cheek, anesthesia in the distribution of the infraorbital nerve, diplopia, or palpable step defect
Tripod Fracture
Maxillary Fractures Le Fort I – maxilla Le Fort II – maxilla,
nasal bones, and medial aspects of orbits (pyramidal disjunction)
Le Fort III – maxilla, zygoma, nasal bones, ethmoids, vomer, and all lesser bones of the cranial base (craniofacial disjunction)
Usually in combination
LeFort Fractures
Blowout Fracture of the Orbit
Fractures of the orbital floor may occur with orbital wall fractures or as an isolated injury.
When the orbital floor, being the weakest area, herniation of orbital contents down into the maxillary sinus may occur (hanging drop sign).
Patients may present with enophthalmos, impaired ocular motility, diplopia due to entrapment of the inferior rectus muscle within the fracture fragments, and infraorbital hypoesthesia.
Maxillofacial Trauma-Specific Fractures
Orbital Fractures› Usually through
floor or medial wall› Enophthalmos› Anesthesia› Diplopia› Infraorbital stepoff
deformity› Subcutaneous
emphysema
Blowout Fracture of the Orbit
This child presented with diplopia following blunt trauma to the right eye. On exam, he was unable to move his right eyeball up on upward gaze.
CT: Blowout Fracture of Orbit
A: Orbital blowout fracture with displacement of the floor (arrow), distortion of the inferior rectus, and herniation of orbital fat through defect. Arrowhead indicates medial fracture.
B: Note opacified left anterior ethmoid air cells and displaced medial orbital fracture (arrowheads).
Maxillofacial Trauma-Specific Fractures
Frontal Sinus/Bone Fractures› Direct blow› Frequent intracranial injuries› Mucopyoceles› Consult with NS for treatment, disposition
and antibiotics Nasoethmoidal-Orbital Injuries
› Lacrimal apparatus disruption› Bimanual palpation if medial canthus pain› CT face
Maxillofacial Trauma-Specific Fractures
Orbital Fissure Syndrome› Fracture of the orbital canal
Extraocular motor palsies and blindness If significant retrobulbar hemorrhage, may
need cantholysis to save vision
Zygomatic Fractures› Tripod fracture
Most serious Lateral subconjunctival hemorrhage Need ORIF
› Arch fracture Most common Outpatient
repair
Maxillofacial Trauma-Specific Facial Fractures Mandibular Fractures
› Second most common facial fracture
› Often multiple› Malocclusion› Intraoral lacerations› Sublingual ecchymosis› Nerve injury
› Plain films› Panorex› CT
› Open Fractures Prophylactic Ab.
Anatomic units of the mandible
Types of fracture
Simple Greenstick fracture (rare, exclusively in
children) Fracture with no displacement (Linear) Fracture with minimal displacement
Displaced fracture
Comminuted fractureExtensive breakage with possible bone and
soft tissue loss Compound fractureSevere and tooth bearing area fractures Pathological fracture(osteomyelities, neoplasm and generalized
skeletal disease)39
Angle’s classification
Favourable or unfavourable
They can be vertically or horizontally in direction
They are influenced by the medial pterygoid-masseter “sling”
If the vertical direction of the fracture favours the unopposed action of medial pterygoid muscle, the posterior fragment will be pulled lingually
If the horizontal direction of the fracture favours the unopposed action of messeter and pterygoid muscles in upward direction, the posterior fragment will be pulled lingually
Favourable fracture line makes the reduced fragment easier to stabilize
41
Panoramic X-Ray Film of the Mandible
Note fractures in left angle and right body of mandible
Multiple fractures are present more than 50% of the time and are usually on contralateral sides of the symphysis
Approach to the Patient with Traumatic Injury of the Face
Facial trauma is defined as injury to the soft tissues of the face (including the ears) and to the facial bony structures.
May result in hemorrhage and airway obstruction accompanied by multisystem involvement (as many as 60% of patients have associated injuries)
Evaluation includes history, physical exam, and diagnostic imaging
Principles of treatmentsimilar to elsewhere fractures in the body
Reduction of fragments in good position
Immobilization until bony union occurs
These are achieved by: Close reduction and immobilization Open reduction and rigid fixation
Other objective of mandible fracture treatment:
Control of bleeding
Control of infection45
Treatment options
No treatment Soft diet Maxillomandibular fixation Open reduction - non-rigid fixation Open reduction - rigid fixation External pin fixation Lag screw
Maxillomandibular fixation
Close reduction
Arch bars
▶ IMF prior to rigid fixation
▶ For the purpose of close reduction
48
Maxillomandibular fixation
Open reduction - nonrigid fixation
Open reduction - Rigid fixation
External Fixation
Lag screw
Special Considerations
TMJ ank. Pediatric Dental root Inf. Alveolar N. airway
Special Considerations
Facial N. Lacrimal ap. Foreign body Borders & margins injury (Vermilion border- nasal ala- eyelids-
helix)
