Maxillofacial trauma

Background

Prehospital Care

• Assess patients ability to speak and protect the airway before and frequently during transport
• Hematomas can significantly distort pharyngeal and facial anatomy making intubation or cricothyroidotomy difficult
• Increased jaw mobility from a mid face fracture may help with intubation
• Penetrating trauma to the lower third of the face frequently requires intubation or a surgical airway
• Place a protective shield over an eye suspected to have a ruptured globe
• Patients should remain upright or reverse trendelenberg if there is oropharyngeal and nasal bleeding to avoid aspiration especially if placed in cervical protection
• Temporizing hemostasis with oral and nasal packing in an intubated patient may help with persistent bleeding
• Transport all avulsed pieces of the face including ears and nose

Pediatric Considerations

• Cricothyrotomy is contraindicated in patients <8yr old
• Maxillary sinuses do not develop until 6 yr old (reduces midfacial fx)
• Pediatric orbital floor is more pliable, more likely to lead to entrapment
• Mandible fracture requires prompt referral (1-2d) due to rapid bone remodeling

Clinical Features

Face

• Numbness
  • Check supraorbital, infraorbital, and mental nerves
• Assess Le Fort by rocking hard palate w/ one hand while stabilizing forehead w/ other

Eye

• Exam
  • Bird's eye view for exophthalmos w/ retrobulbar hematoma
  • Worm's view for endophthalmos (blow-out fx) or malar prominence flattening (zygoma fx)
• Acuity
• Diplopia
  • Binocular diplopia suggests entrapment of EOM
  • Monocular diplopia suggets lens dislocation
• Extraocular motion
  • Limitation on upward gaze occurs w/ fracture of inf and medial orbital wall
• Pupil
  • Teardrop sign (globe rupture), hyphema, reactivity (swinging flashlight test)
• Pressure (only if r/o globe rupture)
  • Check in patients w/ exophthalmos, afferent nerve defect or e/o retrobulbar hematoma
• Fat through wound = septal perforation
• Raccoon eyes

Nose

• Crepitus over any facial sinus suggests sinus fx
• Septal Hematoma
• Make sure simple nasal fracture isn't a complex naso-orbito-ethmoid injury

Ears

• Auricular Hematoma
• CSF leak
• Hemotympanum
• Battle Sign

Oral

• Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury
• Mandible Fracture
  • Place finger in auditory canal while patient opens and closes jaw to detect condyle fx
  • Tongue blade test
    • 95% Sn for no fracture if can bite down hard enough to break it when twisted by examiner
  • Jaw deviation due to mandible dislocation or condyle fx
    • Chin will point away from dislocation, towards a fracture
• Malocclusion occurs in mandible, zygomatic, and Le Fort fx
• Lacerations and mucosal ecchymosis suggests mandible fx

Differential Diagnosis

Maxillofacial Trauma

• Ears
  • Auricular hematoma
• Nose
  • Nasal fracture
  • Nasal septal hematoma
• Oral
  • Dental trauma
  • Lip laceration
  • Tongue laceration
• Other face
  • Le Fort fractures
  • Mandible fracture
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture
• Related
  • Head trauma (main)
    • Skull fracture
    • Skull fracture (peds)
    • Basilar skull fracture
  • Orbital trauma
    • Eyelid laceration
  • Scalp laceration

Diagnosis

• Suspect midface fracture > facial CT
• Suspect orbital floor fracture > orbital CT
• Suspect mandibular fracture
  • Mandibular series
    • Body fracture > oblique view
    • Angle/symphysis fracture > PA view
    • Condyle fracture > AP axial (Towne's) view
• Plain Films
  • Water's view
    • Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
  • Bucket handle view
    • zygomatic arches

Disposition

• Bedside consult is necessary for:
  • Decreased vision
  • Tripod Fracture
  • Le Fort Fracture
  • Open Mandibular Fracture
  • Frontal Sinus Fractures with intracranial involvement

See Also

• Head Trauma (Main)