Facial Trauma

1. Facial Trauma Joni Skipper, MS-IV USC School of Medicine

2. Diagnosis? • This child presented with diplopia following blunt trauma to the right eye. On exam, he was unable to move his right eyeball up on upward gaze.

3. Blowout Fracture of the Orbit • Fractures of the orbital floor may occur with orbital wall fractures or as an isolated injury. The isolated injury is usually caused by application of pressure to the globe of the eye by objects with a radius of curvature of 5 cm or less. When the orbital floor, being the weakest area, gives way, herniation of orbital contents down into the maxillary sinus may occur (hanging drop sign). • Patients may present with enophthalmos, impaired ocular motility, diplopia due to entrapment of the inferior rectus muscle within the fracture fragments, and infraorbital hypoesthesia.

4. CT: Blowout Fracture of Orbit • A: Orbital blowout fracture with displacement of the floor (arrow), distortion of the inferior rectus, and herniation of orbital fat through defect. Arrowhead indicates medial fracture. • B: Note opacified left anterior ethmoid air cells and displaced medial orbital fracture (arrowheads).

5. Approach to the Patient with Traumatic Injury of the Face • Facial trauma is defined as injury to the soft tissues of the face (including the ears) and to the facial bony structures. • May result in hemorrhage and airway obstruction accompanied by multisystem involvement (as many as 60% of patients have associated injuries) • Evaluation includes history, physical exam, and diagnostic imaging

6. What was the mechanism of injury? Was the patient mobile, restrained, or stationary? Is the injury the result of blunt or penetrating trauma? Was the object that caused the injury mobile or stationary? Can the degree of energy transfer be estimated? Are there any associated thermal or chemical injuries present? History of Traumatic Event

7. Where is the location of any facial pain or numbness? Are there vision problems, such as diplopia, present? Does movement of the mandible produce pain? Is there an abnormal “bite” present? Additional History

8. The External Bony Facial Skeleton • Composed mainly of the frontal bone, temporal bones, nasal bone, zygomas, maxilla, and mandible. • Ethmoid, lacrimal, sphenoid bones contribute to inner portion of orbits • Upper third - above superior orbital rim • Middle third (midface)- superior orbital rim down through maxillary teeth • Lower third - mandible

9. Bones of the Facial Skeleton

10. Physical Examination • First, inspect face for deformity and asymmetry • Enophthalmos, proptosis, ocular integrity, ocular movements • Nasal septum for position, integrity, and presence of septal hematoma • Epistaxis or CSF rhinorrhea

11. Physical Examination • Complete neurological exam must be performed on any patient with suspected facial trauma • Sensation - test all 3 major branches of the trigeminal nerve • Motor function - assess facial nerve by having patient wrinkle forehead, smile, bare teeth, and close eyes tightly

12. Physical Examination • Palpation of facial structures - the infraorbital and supraorbital ridges, zygoma, nasal bones, lower maxilla, and mandible • Assess for tenderness, bony deformities, crepitus, and false motion • Malocclusion or step-off in dentition may be sign of mandibular fracture

13. Diagnostic Imaging • Should focus on bony integrity, fluid-filled sinuses, herniation of orbital contents, and subcutaneous air • Overall status of the patient, physical exam findings, and the clinician’s initial impression determine timing and nature of imaging ordered

14. Plain films • Traditionally the mainstay in the radiographic evaluation of facial trauma • Standard plain film facial series: Waters (occipitomental), Caldwell (occipitofrontal), and lateral views • Panoramic films are used to best evaluate mandibular fractures

15. CT • Offers a viable, cost-effective alternative to plain films • Very helpful in the evaluation of facial trauma when facial edema, lacerations, other injuries, or altered level of consciousness limit usefulness of clinical exam • Consider institutional wait and turnaround time

16. MR • Limited role of MR in evaluation of facial trauma due to insensitivity of MR to fractures • Used to provide complimentary information to CT in the evaluation of the eye and its associated structures

17. Bone Force of gravity (g) Nasal bones 30 Zygoma 50 Angle of mandible 70 Frontal-glabellar region 80 Midline maxilla 100 Midline mandible (symphysis) 100 Supraorbital rim 200 Force of Gravity Impact Required for Facial Fracture

18. Nasal Fractures • Most common site of facial trauma due to location • May be displaced laterally or posteriorly • Requires control of epistaxis and drainage of septal hematoma, if present

19. Zygomatic Fractures • Tripod fracture: zygomaticofrontal suture, zygomaticotemporal suture, and infraorbital foramen • Present with flatness of the cheek, anesthesia in the distribution of the infraorbital nerve, diplopia, or palpable step defect

20. Maxillary Fractures • Le Fort I – maxilla • Le Fort II – maxilla, nasal bones, and medial aspects of orbits (pyramidal disjunction) • Le Fort III – maxilla, zygoma, nasal bones, ethmoids, vomer, and all lesser bones of the cranial base (craniofacial disjunction) • Usually in combination

21. Mandibular Fractures • Any patient with malocclusion after facial trauma is assumed to have mandibular fracture until proven otherwise

22. Panoramic X-Ray Film of the Mandible • Note fractures in left angle and right body of mandible • Multiple fractures are present more than 50% of the time and are usually on contralateral sides of the symphysis