Facial Injuries Module

It is important to treat facial injuries as head injuries and include any questions regarding head injury in your initial history. Delve further into the events surrounding the injury – how long did the epistaxis last? Was there any loss of consciousness, amnesia, or vomiting? If there are no red flags that warrant a CT scan, be sure to screen for concussion, and give written advice regarding cognitive rest and gradual return to school and sports if necessary. 

On examination – visually inspect the face and nose looking for deformity and asymmetry. Ask regarding the previous appearance of the nose (not all deformities are acute!). Any saddle nose deformity or telecanthus warrants investigation for naso-orbital-ethmoidal fracture. Look closely at the orbits – assessing for conjunctival haemorrhage, panda eyes, pupillary reflexes, and eye movements. Check visual acuity, and visual fields and ask about diplopia. Visually inspect the nasal cavity looking for active epistaxis, septal deviation, and septal haematoma. Ask the patient to occlude one nostril and breathe through the other on each side. Ask the patient to open their mouth – look for posterior epistaxis or oral trauma. 

Palpate the facial bones laterally to medially (any possibility of pain should be kept until last – that way you stay friends longer) feeling for pinpoint tenderness or a step. Assess the sensation of the infraorbital nerve. 

If the history and examination are consistent with a nasal bone fracture, there is no need for further imaging. Any septal haematoma must be urgently evacuated to avoid necrosis of the septum and resultant deformity. The patient should be discussed with local Max-Fax / ENT services and provided with a clinic appointment for the near future for possible closed reduction and external fixation if necessary. 

Have a look at this video hosted by NEJM demonstrating nasal septal haematoma drainage.

All patients should be managed from an ABCDE approach. This girl has a patent airway and no respiratory or cardiovascular compromise. Her most immediate concern currently is pain which must be addressed before the examination is attempted. Oral ibuprofen and oral or rectal paracetamol can be used, but if the patient is in apparently acute severe pain, intranasal fentanyl can be used as an adjunct which will give immediate relief. Check out this post on analgesia in paediatrics.

After the patient has been given adequate analgesia, examination reveals no obvious facial deformity or bruising, but she is unwilling to open her mouth more than a few millimetres. She flinches when any attempt is made to palpate the left side of her jaw. You suspect a mandible injury.

Mandibular fractures are more common in children than in adults due to the ratio of medullary bone surrounded by thin cortical bone. Unlike adults which subscribe to the polo mint rule – that there must be two fracture sites – they can only have one. Condylar fractures are the most common, of which approximately 20% are bilateral. Of all mandible fractures, condylar fractures pose the highest risk of growth disturbance and joint hypermobility.

Always assess patients with facial trauma for other injuries (75% of mandibular fractures in children have other injuries) and pay particular attention to the cervical spine.

Other signs that indicate mandibular fractures include gingival wounds, mobile teeth segments, buccal or sublingual haematoma, and bleeding from the auditory canal with condylar fractures.

Mandibular imaging usually consists of an OPG and a PA mandible. However, for uncooperative patients, lateral views or a CT scan may be required. CT scan may also be required to assess for TMJ dislocation or comminuted fractures. 

Take a look at this DFTB post on mandible x-ray interpretation.

The inferior alveolar nerve can be damaged in mandibular injuries which travels adjacent to the lingual cortical surface on the inferior border of the mandible. Its branch the mental nerve exits the mental foramen and provides sensation to the chin and lower lip.  

This patient must be discussed with on-call Max Fax colleagues. Often paediatric mandibular fractures are treated conservatively, however, if there is any blocking movement of the jaw then open fixation is required. 

Read more about these injuries, including mandibular dislocations, in this DFTB post on mandibular injuries.

The orbit is a complex structure that is pyramidal in shape. In young children, due to the prominence of the frontal bone which bears the brunt of most trauma, the roof is more likely to be fractured. With direct trauma to the orbit, the globe is less likely to rupture than the floor is to fracture. 

It is imperative to assess the conjunctiva, visual acuity, pupillary reflexes, visual fields, eye movements, and sensation of infraorbital nerve. Beware of the ‘white eye’ blowout fracture which is when there is no obvious globe injury, however, there is limited or no movement on upward gaze. An orbital blowout fracture can cause a trapdoor effect, where soft tissue has been trapped by the movement of the orbital floor. This injury requires urgent surgical intervention and discussion with Max Fax and Ophthalmology.

With an abnormal examination and a vomiting patient, it is reasonable to forego facial x-rays in favour of CT to avoid unnecessary radiation. The sign to look out for on X-ray of orbital fracture is the teardrop sign which is herniated muscle or fat visible at the roof of the maxillary sinus, and the black eyebrow sign, which signifies orbital emphysema, usually a medial fracture through to the ethmoid sinus.

The oculo-cardiac reflex could be the cause of this child’s vomiting. It is mediated by connections between the ophthalmic branch of the trigeminal nerve and the vagus nerve. It can be associated with haemodynamic instability, hypotension, and bradycardia. It is yet another reminder of why we proceed with the ABC assessment of all patients in the first instance. Another cause could be rising intracranial pressure, and a CT brain is warranted. Early discussion with ophthalmology is essential, sometimes (not in the case of haemodynamic instability caused by the oculo-cardiac reflex) surgery is delayed for steroid therapy to prevent further optic nerve damage.

Severe pain in an eye injury can be indicative of a retrobulbar haematoma. This causes increased pressure resulting in proptosis, blurred vision and an afferent pupillary defect. The only treatment is urgent lateral canthotomy. Have a look at this video from EM:RAP on how to perform a lateral canthotomy. 

Read more about orbital fractures in this DFTB post.

This case is one that should follow strict trauma life support protocols, and the candidates should be careful not to be distracted by obvious injuries. In the first instance, a trauma call should be made.

This patient should be immobilised with c-spine precautions. The presence of severe facial injuries is concerning regarding his airway. Lying flat with bleeding wounds increases the risk of aspiration and airway occlusion. His airway should be assessed for blood/teeth / debris and suctioned if necessary.

Head tilt is inappropriate due to the spinal precaution, and so jaw thrust would be the airway manoeuvre needed to maintain a patent airway. In this case, early intubation would be appropriate due to airway compromise and patient distress. After the airway is secured the rest of the ABC primary survey can be completed, including trauma imaging and advanced surgical skills as required. Children are at increased risk of hypothermia and haemodynamic instability in trauma and must be constantly reassessed.

These two #DFTB19 talks are definitely worth signposting:

Taking your trauma team to the next level: Anna Dobbie
Maturing your approach to trauma: Anne Weaver

No thoracic, abdominal, pelvic, or long bone injuries are detected during the child’s primary survey. Imaging of the brain, c-spine, and facial bones show a frontal subdural haematoma, a Le Fort II fracture, and fractured C4.

Maxillary fractures are classified according to the Le Fort classification system.

1. Le Fort I: A horizontal fracture through the floor of maxillary sinuses with the teeth contained within the detached fragment. Only palate moves.
2. Le Fort II: A fracture which can be one-sided or bilateral fracture through the maxilla extending into the floor of the orbit, the nasal cavity and hard palate. This results in a pyramidal shaped fracture.
3. Le Fort III: A fracture through the orbits in which the entire maxilla and one or more facial bones, the entire midface, becomes separated from the base of the skull. This is called craniofacial disjunction.

This patient naturally requires discussion with neurosurgical services, orthopaediacs, and maxillofacial surgeons. His c-spine must remain protected and he is likely to require the evacuation of the frontal subdural. He also requires a thorough secondary survey. In this case, one of the mainstays of treatment is to prevent secondary brain injury.

He should be lying at a 30-degree tilt (still in spinal precautions), his temperature, glucose, and end-tidal CO2 should be kept in tight parameters, and an anticonvulsant should be given if there’s concern that he might have a seizure. Neurosurgery may request mannitol or hypertonic saline depending on scan results.

He should also receive tetanus cover and antibiotics for open facial fractures.

For further reading about neuroprotection in traumatic brain injuries, have a look at this Paediatric FOAM post.

Read more about maxillary fractures in this DFTB post.

Facial injuries require a full examination from all sides; look for facial flattening from a bird’s eye view and enophthalmos from a worm’s eye view. Ipsilateral epistaxis can be severe; remember to check the back of the throat for a posterior bleed (this also helpfully assesses movement of the mandible). As always inspect the eye, and look for subconjunctival haemorrhage with no lateral border.

Any patient with a suspected ZMC fracture requires a full and thorough cranial nerve examination. The sensory branches of cranial nerve V2 (infraorbital, zygomaticofacial, and zygomaticofrontal) all run in close proximity to the zygoma and can be damaged easily. This results in numbness of the cheek, upper lip, nose, and maxillary dentition if the infraorbital nerve is damaged (usually where it exits the infraorbital foramen), and numbness of the lateral cheek and anterior temporal area if the zygomaticofacial or zygomaticofrontal nerves are damaged (usually where they exit the zygoma by their eponymous foramina). If the fracture is severe, it can damage the facial nerve as it crosses superficial to the arch resulting in an ipsilateral facial palsy. 

Facial xrays can show these fractures, but a CT is the gold standard, particularly if there is any obvious deformity or neurological deficit which will require operative management. 

This patient should receive tetanus and antibiotics given it is an open fracture. Some ZMC fractures in children are treated conservatively with decongestants and antibiotics (they are often greenstick with no great cosmetic or neurological sequelae), however, others require careful operative management, with the goals of treatment to restore form and function, without compromising future bone growth. Discussion with max fax on call is required. The patient should be advised against nose blowing in the interim!

Read more about zygomatic complex fractures in this DFTB post.

A patient with a mandibular fracture may also complain of:

A. Loss of taste

B. Tingling or loss of sensation of the upper lip

C. Trismus

D. Tingling or loss of sensation of the lower lip and chin

The correct answer is D.

Due to damage to the inferior alveolar nerve as it exits the mental foramen.

A patient with an obvious deformity to their left zygomatic arch also appears to have a facial droop. This is due to damage of what structure?

A. Cranial nerve V

B. Cranial nerve VI

C. Cranial nerve VII

D. Infraorbital nerve

The correct answer is C.

The facial nerve can be damaged in extreme cases of facial trauma, leading to paralysis of the ipsilateral facial muscles.

A blowout fracture will cause the inability of:

A. Lateral gaze

B. Upward gaze

C. Medial gaze

D. Inferior gaze

The correct answer is B.

Due to entrapment of the inferior rectus muscle.

Which of the following would require emergent intervention in a nasal fracture?

A. Dorsal swelling

B. Septal deviation

C. Septal haematoma

D. Loss of sense of smell

The correct answer is C.

Before septal necrosis develops.

Open fractures require:

A. IV antibiotics

B. Tetanus status assessment

C. Thorough washout

D. All of the above

The correct answer is D – All of the above.

Which of these is NOT part of the conservative management of a ZMC fracture?

A. Avoidance of nose blowing

B. Soft diet

C. Prophylactic antibiotics

D. Nasal decongestants

The correct answer is B.

Which fractures of the mandible pose the highest risk of growth disturbance and joint hypomobility?

A. Condyle

B. Body

C. Angle

D. Ramus

The correct answer is A.