Facial Trauma Dr. Nadia Al Hajri

Outline

• Epidemiology.• Types of facial injuries.• Fractures and dislocation• Diagnostic modalities• Management• Neck injuries• Anatomy• More of MCQs.

What is the most common cause of facial trauma?

A.AltercationsB.Animal bitesC. Child abuseD.Motor vehicle collisionsE. work- related injuries

Epidemiology

MVCs previously were the most common cause of facial injuries, but reduced by using:

Windshield improvements. Safety belts. Air bag vehicles.Common in motorcyclists with significant association between

facial injuries and brain injuries.81% of domestics violence associated with maxillofacial trauma.Facial injuries are common areas in children suspected of being

victim of abuse.

Which of the following studies is the best for the initial evaluation maxilla, maxillary sinuses, floors, and inferior rims of the orbits, and the zygomatic arches?

A. Axial CT scan of the headB. Coronal CT scan of the head C. Lateral view of the facial bones D. Posteroanterior view of the facial bonesE. Waters’ projection

Diagnostic Strategies

Midface or maxillary fractures:• Water’s or occipitomental veiw (stable patient).• CT scan if: +ve plain x-ray , unstable patients and complex fractures. ( corononal and sagittal or 3 dimension reconstruction)

Mandible injuries: Panorex radiographs. Coronal CT for condyle fractures.

Diagnostic stratigies

Nasal bone x-rays:

If there tenderness and swelling of nasal bone

+1)Septal hematoma.2) can not breath from one of the nostrils.3)Nose is not straight.

A 17-year-old intoxicated unrestrained front seat passenger was thrown from a convertible when it struck a tree. Respirations are agonal, blood pressure is 60 and palpable, glasgow coma scale is 7, blood is present from the right ear canal, the maxilla and nasal bones are freely mobile on both sides, and rhinorrhea is present. Which of the following would be a treatment priority?

A. Immediate orotracheal intubation or surgical cricothyrotomy.

B. Nasotracheal intubation with direct laryngoscopy and magill forceps.

C. Opening the airway with the head-tilt/chin-lift method.D. Immediate portable cross-table lateral radiograph of the

cervical spine.E. Surgical consultation for tracheostomy in the operating

room.

Management• A, B, C,..Pre-hospital care• Anticipation of difficult airway.Patent airway, speak without difficulty and short transfer

time-> no intervention.Awake orotacheal intubation.In Emergency department Fiberoptic awake intubation. Emergency cricothyroidotomy. LMA ???*Mandibular fractures may be easier.

Type Of Injuries

• Soft tissue injuries.• Fractures and dislocation.

5- which of the following principles regarding the management of facial wounds is true?

A. Beveled lacerations should be debrided parallel to the lacerated edges to preserve orientation with the opposite side and alow for improved closure

B. Debris embedded in traumatic abrasion should be removed by a consulting plastic surgeon 3 to 4 days after the accident to allow easier removal and facilitate a better cosmetic outcome

C. Dg bite puncture wounds to the face should be copiously irrigated, explored for deep tissue injury, and closed primarily

D. Relatively clean facial wounds may be repaired up to 24 hours after injury

E. Quality of the final result is compromised in facial fractures not treated within 48 hours of the accident

7- all the following management principles are true for soft tissue injury except which one?

A. Debridement of facial wounds should be avoided because this may extend wound margins and aggravate bleeding

B. Facial wounds should be carefully explored before closingC. Tetanus prophylaxis is an initial concern D. The width of the wound edges before skin sutures are

placed is an approximate gauge of the width of the resultant scar

E. Wounds up to 24hours old may be closed on the face

8- which of the following is true regarding the management of facial wounds?

A. Deep layers are best closed with running locked stitches for added strength

B. Monofilament synthetic nonabsorbable sutured are the preferred choice for skin closure on the face

C. Nonabsorbable sutures of 4-0 or 5-0 size should be used to approximate deep layers

D. The skin does not regain adequate tensile strength for 2-3 weeks after repair

6- which of the following facial injuries should be referred to an appropriate specialist?

A. Laceration near the medial canthus not involving the lacrimal system

B. Laceration of the outer ear, including cartilage C. Laceration of the cheek with blood at the opening of

Stinson’s duct D.Through-and-through laceration of the nose with

associated fractured cartilageE. Through-and-through laceration of the nose

associated with fractured cartilage.

10- a 27-year-old woman was unrestrained driver of a car that was rear ended just before arrival at the emergency department. She complains of a sore nose. Examination reveals a large grape-like swelling over the left side the nasal septum. What is the most appropriate action?

A. Checking prothrombin time and partial thromboplastin time for possible coagulopathy

B. Closed reduction of the nasal septum with follow-up by an otorhinolaryngologist

C. Incision and drainage of a septal hematoma with anterior packing D. Referral to an otorhinolaryngologist advising the patient to be seen within

1 weekE. Referral to an otorhinolaryngologist for treatment of her nasal polyps

9- a 32-year-old woman playing tennis sustains a blow to her left eye. She complains of pain in her left eye but denies flashes of light, floaters, diplopia, or decrease in vision. Initial examination reveals 20/20 vision in both eyes, functioning extraocular muscles, and an intact globe. Orbital emphysema is noted surrounding her left eye however, and the patient begins to complain of decreased visual acuity in this eye. What step should be taken next?

A. Ballottement of the globe started immediately in an attempt to dislodge the clot causing the central retinal artery occlusion

B. Intra orbital needle aspiration or lateral canathotomy with cantholysis to release pressure under the orbit

C. Ophthalmologic consult for traumatic retinal tear with vitreous hemorrhage

D. Topical cycloplegics (5% homatropine) to the affected eye for treatment of traumatic iridocyciltis with an ophthalmologic follow-up

Injuries to the orbitOrbital hematoma: retrobulbar hematoma Acute exophthalmos-> compression of retinal

artery-> blindness. Orbital emphysema Associated with fracture of medial wall-> air

filled space.Management Lateral canthotomy with cantholysis. Needle aspiration of entrapped air.

A 32-year-old man was involved in a barroom altercation. He arrived at the emergency department complaining of double vision and right –sided facial numbness after sustaining numerous blows to the head and face. Physical examinations reveals right-sided enophthalmos and inability to gaze upward with the right eye. What would be appropriate emergency department management of this patient’s condition?

A. Careful follow-up with the ophthalmologist for an orbital blowout fracture

B. Immediate neurosurgical consultation of traumatic intracranial hemorrhage

C. Nonsteroidal antiinflammatory agents and reassurance that his vision will improve once the swelling resolves

D. Blood alcohol level since these symptoms are most likely secondary to ethanol intoxication

E. Serum Lyme titers and an infectious disease consult

Blowout fractureSigns enophthalmos • Diplopia on upward gaze. • Anesthesia over the anteromedial cheek and upper

lip. Management• immediate repair is not necessary.• careful follow-up is required.• Repair with persistent enophthalmos or diplopia. • patching for comfort • not to drive until the diplopia is resolved.

Zygomatic Fractures

• The zygoma has 2 major components:– Zygomatic arch– Zygomatic body

• Blunt trauma most common cause.• Two types of fractures can occur:– Arch fracture (most common)– Tripod fracture (most serious)

• Palpable bony defect over the arch

• Depressed cheek with tenderness• Pain in cheek and jaw movement• Limited mandibular movement

Zygoma Arch FracturesClinical Findings

• Radiographic imaging:– Submental view

(bucket handle view)

• Treatment:– Consult maxillofacial

surgeon– Ice and analgesia– Possible open

elevation

Zygoma Arch FracturesImaging Studies & Treatment

Zygoma Tripod FracturesClinical Features

• Clinical features:– Periorbital edema and

ecchymosis– Hypesthesia of the

infraorbital nerve– Palpation may reveal

step off– Concomitant globe

injuries are common

Zygoma Tripod FracturesImaging Studies

• Radiographic imaging:– Waters, Submental and

Caldwell views

• Coronal CT of the facial bones:– 3-D reconstruction

Zygoma Tripod FracturesTreatment

• Nondisplaced fractures without eye involvement– Ice and analgesics– Delayed operative consideration 5-7 days– Decongestants – Broad spectrum antibiotics – Tetanus

• Displaced tripod fractures usually require admission for open reduction and internal fixation.

Maxillary FracturesLeFort I

• Definition:– Horizontal fracture of

the maxilla at the level of the nasal fossa.

– Allows motion of the maxilla while the nasal bridge remains stable.

Maxillary FracturesLeFort II

• Definition:– Pyramidal fracture

• Maxilla• Nasal bones • Medial aspect of the

orbits

Maxillary FracturesLeFort III

• Definition:– Fractures through:

• Maxilla• Zygoma• Nasal bones• Ethmoid bones• Base of the skull

Maxillary FracturesTreatment

• Secure and airway• Control Bleeding• Head elevation 40-60 degrees• Consult with maxillofacial surgeon• Consider antibiotics• Admission

Mandible FracturesClinical findings

• Mandibular pain.• Malocclusion of the teeth• Separation of teeth with

intraoral bleeding• Inability to fully open

mouth.• Preauricular pain with

biting. • Positive tongue blade test.

Mandibular FracturesTreatment

• Nondisplaced fractures:– Analgesics– Soft diet– oral surgery referral in 1-2 days

• Displaced fractures, open fractures and fractures with associated dental trauma– Urgent oral surgery consultation

• All fractures should be treated with antibiotics and tetanus prophylaxis.

• Clinical features:– Inability to close

mouth– Pain– Facial swelling

• Physical exam:– Palpable depression– Jaw will deviate away– Jaw displaced anterior

Mandibular Dislocation

• The mandible can be dislocated:– Anterior 70%– Posterior– Lateral– Superior

• Dislocations are mostly bilateral.

Which of the following is true regarding temporo-mandibular joint (TMJ) dislocation

• A) Most of them are posterior• B) The patient is unable to open the mouth in bilateral

dislocations• C) The jaw is rotated toward the affected side in unilateral

dislocation• D) The patient will present with a protruding mouth• E) All of the above

Mandibular Dislocation

• Treatment:– Muscle relaxant– Analgesic– Closed reduction in the

emergency room

Mandibular Dislocation

• Treatment:– Oral surgeon consultation:• Open dislocations• Superior, posterior or lateral dislocations• Non-reducible dislocations• Dislocations associated with fractures

A 25 year old man is punched in the face at a bar and presents to you with dental pain. On examination, his right lower first premolar has a fractrue exposing yellowish surface. No blood is seen on on the tooth. Which of the following is the correct type of fracture and what is the proper management?

• A) Ellis I; follow up in dental clinic in one week

• B) Ellis I; follow up in dental clinic next day• C) Ellis II; follow up in dental clinic in one

week • D) Ellis II; follow up in dental clinic next day• E) Ellis III; immediate dental consult

Management of Dental fractures

• Ellis Type 1 non painful can wait for outpatient follow up• Ellis Type 2 may be painfulDressing by calcium hydroxide, aluminum foil• Ellis type 3Very evaluation and need early evaluation by

dentists

Which of the following is true regarding avulsed and subluxed teeth

• A) Avulsed teeth can almost always be successfully reimplanted if returned to their sockets within 3 hours

• B) Avulsed primary teeth are never reimplanted• C) The best known transport medium for avulsed teeth is

milk• D) Teeth can be temporarily be secured for up to 1 week with

a periodontal pack made from resin and catalyst paste• E) Avulsed teeth should be scrubbed with a povidone-iodine

sponge to kill microbes before reimplimentation

Neck Trauma

Neck InjuriesNeck trauma mechanisms: blunt penetrating strangulation or near hanging. The types of injuries: airway (laryngotracheal), digestive tract (pharyngoesophageal), vascular system neurologic system

Neck Zones

Neck divided into 3 zones– Zone 1 – sternal notch to cricoid– Zone 2 - cricoid to angle of mandible – Zone 3 - angle to occiput

1- Injury to which zone of the neck leads to the highest mortality rate?

A.Zone 1 B.Zone 2C.Zone 3D.Zone 4

Death from Neck Trauma• 1. Airway compromise• 2.Hemorrhage• 3. Associated CNS injury

2- A young male comes to the ED with a stab wound to the neck, resulting in a large hematoma is distorting normal airway anatomy. Vital signs are recorded as follows: heart rate, 94; respiratory rate, 28; and blood pressure, 140/95. there is no evidence of stridor. What would be the proper technique for controlling the airway of this patient?

A. A wake oral intubation with local anesthesia B. Blind nasotracheal intubation C. Immediate cricothyrotomy D. Rapid-sequence induction with endotracheal intubation E. Immediate consult of a trauma surgeon for placement of a

tracheostomy.

3- A previously stable patient with a gunshot wound to the neck suddenly develops tachypnea, tachycardia, hypotention, and machinery-like heart murmur. What should the physician do immediately?

A. Perform a needle aspiration of the right ventricle of the heart B. Place bilateral chest tube C. Place the patient in a seated upright position D. Place the patient in the left lateral decubitus position in

Tredelenburg E. Administer a fluid challenge of 20 cc/kg

4- paramedics radio in about a 25-year-old female with a stabbing injury to the right side of her neck just under her chin. The patient is awake and is tachypneic to 28 but is maintaining her airway. Her pulse is 115 and blood pressure 93/50. Paramedics report she is bleeding briskly, and they have an 8-minute transport. What should orders include?

A. Assessment of wound depth and tissue involvement in order to evaluate the extent and nature of hemorrhage

B. Direct transfer to the operating room on arrival, with early notification of the OR stuff and trauma surgeon

C. Immediate intubation because the patient is tachypneic and in danger of losing her airway

D. Placement of two intravenous catheters for volume resuscitation, with frequent assessment of vital sings and placement of MAST trousers should bleeding continue

E. Placement of two intravenous catheters for volume resuscitation and direct application of external pressure to the site of bleeding

5- A tachycardiac, hypotensive patient with penetrating neck trauma and bleeding into the orophaynx presents to a low-volume, single-coverage emergency department. The nearest appropriate trauma centre is 15 minutes away and is ready to accept the patient. Before transfer, what should the physician do?

A. Rapidly prepare the patient for transport without further delay and send the patient with a transport nurse certified in ACLS

B. Secure an airway, place on oropharynx with heavy gauze, and establish intravenous access with fluid and blood product resuscitation

C. Secure an airway, place an orogastric tube to decompress the stomach of both air and swallowed blood, and establish intravenous access with fluid and blood product resuscitation

D. Transfer the patient only after completing full primary and secondary surveys, including C-spine, chest and pelvis radiographs

E. Transfer the patient only if the platysma has been penetrated

6- A patient who was struck in the side of the head and face with a crowbar is experiencing decreasing levels of consciousness, with unilateral limb paresis and Horner’s syndrome. What is the most likely diagnosis?

A.Air embolus B.Brachial plexus injury C. Carotid artery thrombosis D.Cervical spine fracture E. Thrombosis of the cavernous sinus

7- What do fractures of the thyroid cartilage caused by blunt injury result in?

A. Aphonia because the anterior vocal cord attachment is invariably disrupted

B. Exacerbation of the normal anatomic landmarks of the neck

C. Mandatory tracheostomy for airway stabilization D. The need for aggressive diagnstic imaging consisting of

computed tomography and rigid bronchoscopy E. The need for voice rest, humidified air, and prophylactic

antibiotics with delayed surgical repair acceptable assuming a secured airway

8- In managing strangulation injuries, which of these is true?

A. Calcium boluses have been shown to improve the postanoxic cerebral circulation, helping to decrease long-term ischemic sequelae

B. Because of the high frequency of respiratory complications, prophylactic antibiotics should be routinely given

C. Intubation is an important adjunct even in the absence of unstable airways

D. Phenobarbital is the drug of choice of postanoxic seizures E. Steroids have been shown to be effective treatment for

both cerebral edema and central neurogenic ARDS

Which of the following is true regarding neck trauma

• A) Delayed neurologic deficits after blunt neck trauma suggest carotid artery dissection

• B) All patients with suspected esphogeal injury should receive barium contrast eshophagram

• C) Zone III injuries are most amenable to surgical exploration• D) All neck wounds should be probed to determine the depth of the

wound and integrity of vital structures• E) Impaled objects should always be removed in patients presenting neck

trauma

A 22 year old woman presents to the ED after a domestic dispute with a boyfriend in which she was stabbed in the neck just lateral to her thyroid cartilage. Which of the following is an indication for mandatory operative exploration?

• A) Palpable thrill• B) Subcutaneous emphysema• C) Violation of the platysma• D) Bruit upon auscultation• E) All of the above

Take home points

• As always with trauma, ABC’s• Early recognition of injuries, stabilization, and rapid

initiation of definitive treatment will minimize morbidity and reduce mortality

• Must rapidly involve or transfer to appropriate trauma surgeons and or neurosurgeons

• Life threats dealt with first