256. Trauma to the Face

General

Check sensation throughout face, check typical eye physical exam findings (EOM, visual acuity, possible interocular pressure, pupil reactivity), ask about malocclusion.

Etomidate and Ketamine good for sedation with intubation in facial trauma due to preserved respiratory drive.

For significant hemorrhage, usually due to sphenopalatine and greater palatine branches of external carotid. Anterior pack first (no posterior packing due to possible intracranial involvement). If still persistent, consult for possible emergent surgery vs IR (anastomosis throughout face so low risk for ischemia). Worst case scenario would be to ligate external carotid.

Frontal Bone Fracture

High-energy mechanism. Increased risk of TBI. Operative repair for through and through fracture to prevent pneumocephalus, CSF leak, infection. isolated anterior table fracture can be discharged with f/u with facial surgeon though will still likely need surgery. Depressed fractures (through and through I’m assuming) usually require IV abx and operative repair.

Orbital Fractures

Blowout fractures: fracture of inferior/medial orbital walls causing adipose tissue, inferior rectus or inferior oblique muscle can herniate and become entrapped. Diplopia with upward gaze. Nano-orbito-ethmoid fracture results in pain with eye movement – needs consult, potential admission for facial/NSGY consult. Repair in 1-2 weeks with adults, children shorter time though consult in ED for possible emergent need depending on entrapment. In adults, fractures develop fibrous union at 10-14 days.

Isolated orbital fractures: Augmentin, decongestant, and avoiding blowing nose. Consider patch for diplopia.

Retrobulbar Hematoma: or malignant orbital emphysema. Can cause ocular compartment syndrome which can lead to ischemic optic neuropathy. Emergent canthotomy reduces ocular pressure and ischemia. Ocular ultrasound may show ‘guitar pick sign.’

Zygoma Fractures

Isolated temporal arch fractures: can be discharged. Will likely need surgery, can cause significant trismus.

Tripod Fracture: zygomatoicomaxillary fracture (zygoma, maxilla, orbit) – deceleration injury with disruption of zygomaticofacial suture, zygomaticotemporal junction, and infraorbital rim. Considered orbit/sinus fracture. Loss of vision or significant displacement requires admission for IV abx and operative repair.

Frontal sinus doesn’t develop until age 6. Maxillary sinus by age 10.

Midfacial Fractures

Facial Buttress concept – face is like scaffolding – 4 horizontal and 4 vertical struts – when 2 or more involved, likely unstable.

LeFort I: transverse fracture departing body of maxilla from pterygoid plate (always fractured in all of them) and nasal septum. Involves hard palate and teeth. Feels like loose upper dentures. Always involves nasal fossa. II: hard palate and nose occurs, though not eye involvement. Always involved inferior orbital rim III: entire face separated from skull. Entire face shifts with globes held in place. Always involves zygomatic arch. IV: LeFort III + frontal bone. Consider getting CTA head/neck for vascular injury for > LeFort II. Usually significant hemorrhage. Likely needs nasal packing. Treatment: Admission, IV abx, and surgical repair. Can have different LeForts for both sides.

Superior orbital fissure syndrome: encroachment on the CN involved within the orbital fissure: CN II (vision), CN III, IV, VI (EOM) and V (usually sensation to forehead – V1). Can look like muscle entrapment though usually diffuse ‘entrapment’ rather than just when looking up, etc. Consider starting steroids to decrease swelling. Needs urgent surgery – if CN II involved, needs emergent surgery – time is vision.

Midface bleeding almost always requires IR intervention rather than surgery. Pack first, then IR.

Mandible Fractures

Second most common facial fractures to nasal fractures. 36% at angle, 21% at body, and 17% at parasymphyoid. Usually multiple fractures with 1 at side of impact and the other on the other side due to ‘ring’ effect. Look for ‘open fracture’ with thorough oral exam. 42% are still unifocal fractures. If stable, place Barton’s bandage: ace wrap over top of head and underneath mandible. Open fractures: tx with abx for similar dental infections (PCN or clindamycin). Open fractures usually require operative repair.

Rapid bone remodeling with callous formation occurs by 1 weeks makes delayed reduction difficult. Usually prompt diagnosis and 1-2 day referral for pediatric facial surgeon.

Tongue blade test: stick blade in mouth and have patient clench with teeth and attempt to break off by twisting. Only 85% sensitive for ruling out mandible fracture.

Other Fractures

Nasal Fractures, Dental Fractures in ENT section. Same goes for facial lacerations.

Questions

 

References/Resources

Tintinalli, Seventh Edition, Chapter 256: Trauma to the Face

Rosens, Chapter 35: Facial Trauma

CrashingPatient.com, Facial Trauma

Facial Trauma, Laura Bontemp, Maryland Trauma Day 2017

 

256. Trauma to the Face

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