Facial Trauma
Joseph Lang, MD
April, 2011
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
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
Mechanisms of Injury
Burn
Blunt force
Laceration/abrasion
Penetrating Trauma
Assessment
Determine mechanism of injury
Quick visual acuity
Examine lids and periorbital structures
Neurologic exam
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
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
Blunt Force Management
Visual acuity
Cardinal movements
Neurologic exam
Do not let pt blow nose
Cover area with saline soaked gauze
Pain management
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
Penetrating Trauma
Visual acuity
Do not remove any objects in eye,
stabilize area
Do not touch eye
We all want to see pictures
Maxillo-Facial Trauma
Blunt trauma much more common than
penetrating
Airway issues of main concern
Neurologic issues
Hemorrhage
Other trauma
Facial bones
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
Facial Fractures
Nasal bone most common
Look for fluid coming from nose (CSF)
Cover area with gauze, ice if available
Control bleeding with compression
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
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
Zygoma Fractures
Refers to cheekbones
Zygoma fractures may affect vision, may
also cause numbness on cheek due to
nerve entrapment
Trismus
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
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
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
Mandible Fractures
Often have dental fractures or subluxed
teeth
May have significant intra-oral debris
Airway issues
Screening test is bite stick test
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
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
Oral Injuries
Includes dental and tongue injuries
Penetrating trauma
Airway issues
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
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
Dental Fractures
85% maxillary teeth
According to one medical website, lists the
top causes, #6 is ice hockey
Intra-oral Lacerations
May require suction
Can cover with saline dressings
If penetrating trauma, and object still in
place, secure object and transport
Facial Gunshot Wounds
High mortality, dependant on angle and
bullet
Bullet may travel in unpredictable pattern
Airway nightmares
Questions
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