Maxillofacial trauma

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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[1]
  • 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 fracture)
  • 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 fracture) or malar prominence flattening (zygoma fracture)
  • 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 evidence of retrobulbar hematoma
  • Fat through wound = septal perforation
  • Raccoon eyes

Nose

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

Ears

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 fracture
    • 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 fracture
      • Chin will point away from dislocation, towards a fracture
  • Malocclusion occurs in mandible, zygomatic, and Le Fort fracture
  • Lacerations and mucosal ecchymosis suggests mandible fracture

Differential Diagnosis

Maxillofacial Trauma

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

See Also

References

  1. ↑ Hollier L. et al. Facial gunshot wounds: A 4-year experience. Journal of Oral and Maxillofacial Surgery. 2011: 59:277-282
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