Facial Trauma

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Facial Trauma

• Joseph Lang, MD
• April, 2011

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Objectives

• Discuss relevant anatomy and physiology
• Discuss identification and emergent treatment
  ocular injuries
• Discuss identification and emergent treatment of
  maxillo-facial injuries
• Discuss identification and emergent treatment of
  dental and oral injuries

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Ocular Injuries

• Eye trauma accounts for 1 of visits to ER
• Often associated with facial fractures
• Approximately 90 of injuries could be prevented
  with protective lenses

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Mechanisms of Injury

• Burn
• Blunt force
• Laceration/abrasion
• Penetrating Trauma

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Assessment

• Determine mechanism of injury
• Quick visual acuity
• Examine lids and periorbital structures
• Neurologic exam

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Ocular Burns

• Assess what chemical, bring in bottle if possible
• Remove contact lens if in place
• Irrigate with saline 1000 cc by drip and remove
  any free foreign bodies

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Blunt Force

• Fist, ball, heavy object
• Direct trauma to globe subconjunctival
  hemorrhage, globe injury
• Injury to surrounding structures orbital wall
  fractures, nerve injury, muscular entrapment or
  hematoma

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Blunt Force Management

• Visual acuity
• Cardinal movements
• Neurologic exam
• Do not let pt blow nose
• Cover area with saline soaked gauze
• Pain management

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Laceration/Abrasion

• Corneal layer is only 5-6 cells thick
• Abrasions heal in 2 days
• Possibility of globe rupture
• Usually does not require treatment in field
  except removal of loose foreign bodies, may
  irrigate in certain situations

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Penetrating Trauma

• Visual acuity
• Do not remove any objects in eye, stabilize area
• Do not touch eye
• We all want to see pictures

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Maxillo-Facial Trauma

• Blunt trauma much more common than penetrating
• Airway issues of main concern
• Neurologic issues
• Hemorrhage
• Other trauma

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Facial bones
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Facial Bone Strength

• High impact
• Supraorbital rim 200 g
• Symphysis mandible 100 g
• Frontal-glabellar 100 g
• Angle of mandible 70 g
• Low impact
• Zygoma 50 g
• Nasal bone 30 g

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Facial Fractures

• Nasal bone most common
• Look for fluid coming from nose (CSF)
• Cover area with gauze, ice if available
• Control bleeding with compression

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Frontal Bone Fracture

• One of the hardest bones to break
• Significant trauma
• Often associated brain/eye injury
• Cover any open areas with saline soaked gauze
• Trauma center

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Orbital Injuries

• Generally refers to structures surrounding globes
• Need to assess globe and vision
• Check extra ocular motion (EOM)
• Do not let pt blow nose

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Zygoma Fractures

• Refers to cheekbones
• Zygoma fractures may affect vision, may also
  cause numbness on cheek due to nerve entrapment
• Trismus

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Maxillary Fractures

• Classified by Le Fort System
• I separates hard palate from bone
• II separates central maxilla and hard palate
  from rest of face
• III craniofacial disassociation entire facial
  skeleton is removed

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Maxillary Fractures

• If suspected, can use gentle pull on upper
  incisor area
• Often associated with other structures such as
  blood vessels, nerve, parotid glands
• Le Fort III almost always has CSF leak
• Difficult airway

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Mandible Fractures

• After nasal bone, most common fracture of face
• Usually 2 fractures
• Open or closed
• May note malocclusion, numbness, dislocation
• Look in preauricular area

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Mandible Fractures

• Often have dental fractures or subluxed teeth
• May have significant intra-oral debris
• Airway issues
• Screening test is bite stick test

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Mandibular Dislocations

• Usually occur from motion that opens mouth widely
  yawning, vomiting, singing
• May occur from seizure or direct trauma
• Anterior most common
• May be unilateral or bilateral

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Pediatrics

• Head is larger in proportion to body than in
  adults
• Up to 60 of children with facial fractures have
  intracranial injury
• Children more likely to have serious
  exsanguination from facial wounds than adults

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Oral Injuries

• Includes dental and tongue injuries
• Penetrating trauma
• Airway issues

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Dental Avulsion

• Primary tooth implantation not done
• Permanent tooth mechanism, time out of socket,
  what tooth was lying in
• Inspect tooth to see if intact
• Inspect site of tooth loss

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Dental Avulsion Care

• Do not touch root or scrub tooth
• May use gentle saline irrigation
• If possible, attempt reimplantation in field
• If unable to reimplant in field, place tooth in
  transport medium Hanks solution, milk, saline

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Dental Fractures

• 85 maxillary teeth
• According to one medical website, lists the top
  causes, 6 is ice hockey

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Intra-oral Lacerations

• May require suction
• Can cover with saline dressings
• If penetrating trauma, and object still in place,
  secure object and transport

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Facial Gunshot Wounds

• High mortality, dependant on angle and bullet
• Bullet may travel in unpredictable pattern
• Airway nightmares

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Questions

• ???