Management of Facial Fractures

Immediate Assessment

Before completing a detailed history and physical evaluation of the facial area, critical injuries that may be life threatening must be addressed. The first step in evaluating a trauma patient is to assess the patient's cardiopulmonary stability by ensuring that the patient has a patent airway and that the lungs are adequately ventilated. Vital signs, including respiratory and pulse rates and blood pressure, should be taken and recorded. During this initial assessment (i.e., primary survey), other potentially life-threatening problems such as excessive bleeding should also be addressed. Immediate measures such as pressure dressings, packing, and clamping of briskly bleeding vessels should be accomplished as quickly as possible. An assessment of the patient's neurologic status and an evaluation of the cervical spine should be completed next. Forces severe enough to cause fractures of the facial skeleton are often transmitted to the cervical spine. The neck should be temporarily immobilized until neck injuries have been ruled out. Careful palpation of the neck to assess possible areas of tenderness and a cervical spine radiographic series should be completed as soon as possible.

Treatment of head and neck injuries generally should be deferred until a thorough evaluation, assessment, and stabilization of the patient has been accomplished. However, some initial treatment is often necessary to stabilize the patient. Management of the patient's airway is of vital importance. Frequently, fractures of the facial bones severely compromise the patient's ability to maintain the airway, particularly when the patient is unconscious or completely supine. Severe mandible fractures, especially bilateral or comminuted fractures, could cause posterior displacement of the mandible and the tongue, which results in obstruction of the upper airway ( Fig. 25.1 ).

Simply grasping, repositioning, and stabilizing the mandible into a more anterior position may alleviate this obstruction. Placement of a nasopharyngeal or an oropharyngeal airway may also be sufficient to temporarily maintain a patent airway. In some cases, endotracheal intubation may be necessary. Any prosthetic devices, avulsed teeth, pieces of completely avulsed bone, or other debris may also contribute to airway occlusion and must be removed immediately. Any areas of bleeding should be quickly examined and managed with packing, pressure dressings, or clamping. All excess saliva and blood must be suctioned from the pharynx to avoid aspiration and laryngospasm.

Injuries to the facial region may involve not only bones of the face but also soft tissue such as the tongue or upper neck areas, or they may be associated with injuries such as a fractured larynx. In some cases, an emergency tracheostomy may be necessary to provide an adequate airway. In trauma patients who have complete upper airway obstruction, a cricothyrotomy is the most rapid way to access the trachea ( Fig. 25.2 ).

History and Physical Examination

After the patient has been initially stabilized, as complete a history as possible should be obtained. This history should be obtained from the patient; however, because of loss of consciousness or impaired neurologic status, information must often be obtained from witnesses or accompanying family members. Five important questions should be considered:

• 1

  How did the accident occur?

• 2

  When did the accident occur?

• 3

  What are the specifics of the injury, including the type of object contacted, the direction from which contact was made, and similar logistic considerations?

• 4

  Did loss of consciousness occur?

• 5

  What symptoms are now being experienced by the patient, including pain, altered sensation, visual changes, and malocclusion?

A complete review of systems, including information about allergies, medications, and previous tetanus immunization, medical conditions, and prior surgeries should be obtained.

Physical evaluation of the facial structures should be completed only after an overall physical assessment that addresses cardiopulmonary and neurologic functions and other areas of potential trauma, including the chest, abdomen, and pelvic areas. Because patients with multiple severe injuries frequently require evaluation and treatment by several specialists, trauma teams have become standard in the emergency departments of major hospitals. These teams usually include general surgeons and specialists in cardiothoracic surgery, vascular surgery, orthopedic surgery, neurosurgery, and anesthesiology; these specialists are on call to provide immediate attention to emergency department patients. Other trauma team specialists include oral-maxillofacial surgeons, ophthalmologists, otolaryngologists, plastic surgeons, and urologists. The combined efforts of these specialists are frequently required to assess and treat the patient's injuries properly.

Evaluation of the facial area should be performed in an organized and sequential fashion. The face and cranium should be carefully inspected for evidence of trauma, including lacerations, abrasions, contusions, areas of edema or hematoma formation, and possible contour defects. Areas of ecchymosis should be carefully evaluated.

Periorbital ecchymosis, especially with subconjunctival hemorrhage, is often indicative of orbital rim or zygomatic complex fractures ( Fig. 25.3 ). Bruises behind the ear, or the Battle sign, suggest a basilar skull fracture. Ecchymosis in the floor of the mouth usually indicates an anterior mandibular fracture.

A neurologic examination of the face should include careful evaluation of all cranial nerves. Vision, extraocular movements, and pupillary reaction to light should be carefully evaluated. Visual acuity or pupillary changes may suggest intracranial (cranial nerve [CN] II or III dysfunction) or direct orbital trauma. Uneven pupils (anisocoria) in a lethargic patient suggest an intracranial bleed (subdural or epidural hematoma or intraparenchymal bleed) or injury. An asymmetric or irregular (not round) pupil is most likely caused by a globe (eyeball) perforation. Abnormalities of ocular movements may also indicate central neurologic problems (CN III, IV, or VI) or mechanical restriction of the movements of the eye muscles resulting from fractures of the orbital complex ( Fig. 25.4 ). Motor function of the facial muscles (CN VII) and muscles of mastication (CN V) and sensation over the facial area (CN V) should be evaluated. Any lacerations should be carefully cleaned and evaluated for possible transection of major nerves or ducts, such as the facial nerve or the Stensen duct.

The mandible should be carefully evaluated by extraorally palpating all areas of the inferior and lateral borders and the temporomandibular joint, paying particular attention to areas of point tenderness. The occlusion should be examined, and step deformities along the occlusal plane and lacerations of gingival areas should be assessed ( Fig. 25.5 ). Bimanual palpation of the suspected fracture area should be performed by placing firm pressure over the mandible posterior and anterior to the fracture area in an attempt to manipulate and elicit mobility in this area. The occlusion should be reexamined after this maneuver. Mobility of the teeth in the area of a possible fracture should also be noted.

The evaluation of the midface begins with an assessment of the mobility of the maxilla as an isolated structure or in combination with the zygoma or nasal bones. To assess maxillary mobility, the patient's head should be stabilized by using pressure over the forehead with one hand. With the thumb and forefinger of the other hand, the maxilla is grasped; firm pressure should be used to elicit maxillary mobility ( Fig. 25.6 ).

The upper facial and midfacial regions should be palpated for step deformities in the forehead, orbital rim, or nasal or zygoma areas. Firm digital pressure over these areas is used to carefully evaluate the bony contours and may be difficult when these areas are grossly edematous. In checking for a zygomatic complex or arch fracture, an index finger can be inserted in the maxillary vestibule adjacent to the molars while palpating and applying pressure superolaterally. Bony crepitus (the ability to feel the vibration as fractured bone edges are rubbed against one another) or extreme tenderness warrants a further workup. An evaluation of the nose and paranasal structures includes measurement of the intercanthal distance between the innermost portions of the left and right medial canthus. Frequently, NOE injuries cause spreading of the nasal bones and displacement of the medial canthal ligaments, resulting in traumatic telecanthus (widening of the medial intercanthal distance; Fig. 25.7 ). Normally the medial intercanthal distance should equal the alar base width. The nose should also be evaluated for symmetry. The bony anatomy of the nose should be evaluated by palpation. A nasal speculum is used to visualize the internal aspects of the nose to locate excessive bleeding or hematoma formation, particularly in the area of the nasal septum.

Intraoral inspection should include an evaluation of areas of mucosal laceration or ecchymosis in the buccal vestibule or along the palate and an examination of the occlusion and areas of loose or missing teeth. These areas should be assessed before, during, and after manual manipulation of the mandible and the midface. Unilateral occlusal prematurity with a contralateral open bite should raise suspicion for some type of jaw fracture.

Radiographic Evaluation

After a careful clinical assessment of the facial area, radiographs should be taken to provide additional information about facial injuries. In cases of severe facial trauma, cervical spine injuries should be ruled out with a complete cervical spine series (i.e., cross-table, odontoid, and oblique views) before any manipulation of the neck. The facial radiographic examination should depend, to some degree, on clinical findings and the suspected injury. Haphazard or excessive radiographic examination is generally not warranted. In the patient with facial trauma, the purpose of radiographs should be to confirm the suspected clinical diagnosis, obtain information that may not be clear from the clinical examination, and more accurately determine the extent of the injury. Radiographic examination should also document fractures from different angles or perspectives.

Radiographic evaluation of the mandible can require two or more of the following four radiographic views: (1) panoramic view, (2) open-mouth Towne view, (3) posteroanterior view, and (4) lateral oblique views ( Fig. 25.8 ). Occasionally even these radiographs do not provide adequate information; therefore, supplemental radiographs, including occlusal or periapical views, may be helpful. Computed tomography (CT) scans, axial views without intravenous contrast medium, may provide information not obtainable from plain radiographs or when cervical spine precautions or other injuries do not permit standard facial films. CT scanning is used to rule out neurologic injury in many patients with facial trauma, and this scan can also be used to supplement the radiographic evaluation. More commonly, these CT images are being obtained as the primary radiographic analysis for patients with facial fractures, therefore eliminating the plain film analysis altogether. In addition, the widespread availability of cone-beam CT in the outpatient setting has allowed for three-dimensional analysis at relatively low radiation doses, therefore replacing multiple plain film analysis.

Evaluation of midface fractures historically has been supplemented with standard radiographic views, including Waters view, lateral skull view, posteroanterior skull view, and submental vertex view ( Fig. 25.9 ). However, because of the difficulty of interpreting plain radiographs of the midface, more sophisticated techniques are currently used. CT is the most commonly used radiographic technique for the evaluation of midface trauma. The ability to evaluate fractures in several planes of space and to visualize the entire skull, midface, and mandible with three-dimensional reconstruction provides invaluable information for diagnosing and treating complex facial trauma ( Fig. 25.10 ).