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^[1]
Place a protective shield over an eye suspected to have a ruptured globe
Patients should remain upright or reverse trendelenburg 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

Patient with poly maxillofacial trauma: (a) Bilateral black eyes. (b) X-ray skull: AP view showing multiple fractures of facial bone including mandible. (c) X-ray skull: lateral view showing multiple fractures of facial bone including mandible. (d) CT scan showing details of facial bone fractures.

Ears

Auricular Hematoma
Signs of basilar skull fracture
- CSF leak
- Hemotympanum
- Battle Sign

Nose

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

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 fractures
Lacerations and mucosal ecchymosis suggests mandible fracture

Other Face

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