Facial Fractures
last authored: Sept 2009, David LaPierre
Introduction
Facial fractures often accompany head and neck trauma.
Add a few details on epidemiology...
The Case of Mr Bight
Mr Bight is a 32 year-old man who is struck by a motorcycle while crossing the street. Among other obvious injuries, he has diffuse brusing and swelling across his face, and his teeth do not meet as they did before the collision.
Q: how would you evaluate his injury?
Relevant Anatomy
Types of Facial Fracture
Approach fractures according to anatomical involvement.
Nasal fracture and dislocations
Rule out septal hematoma, as it can lead to cartilaginous death and saddle deformity.
Nasal fractures are clinical diagnoses, presenting with tenderness and mobility.
Frontal Sinus fracture
Usually high impact. If the posterior wall is fractured, the brain may be able to communicate with the frontal sinus and
Zygomatic fractures
- bruising
- swelling
- pain
- subconjuctival bleeding
undisplaced: nonoperative
minimally displaced: Gilles elevation using a crowbar
largely displaced
Nasoorbitoethmoid fractures
often from high velocity injuries
usually disfiguring, with a flattened nose and telecanthus (widened eyes)
swollen medial canthal area and tear of the medial palpebral ligaments
lack of skeletal suuport on palpation of nose
CSF rhinorrhea is of concern
surgical approach:
coronal,
Frontal sinus
forehead laceration
forehead depression
CSF rhinorrhea
V1 neuralgia
can treat with exploration and fracture reduction, obliteration, or cranialization
Maxillary Fractures
biology: 3 vertical butresses nasomaxillary, zygomaticomaxillary, pterygomaxillary
and 4 horizontal butresses
There are three types of maxillary fractures:
- LeFort I: separation of maxilla below nose
- LeFort II: pyramidal fracture
- LeFort III: craniofacial dysjunction along the zygomaticofrontal suture.
Mandibular fractures
- most common in MVCs, falls, fistfights, missile injuries, and sports accidents
- most commonly classified according to anatomy
- condylar fractures
- body fractures
- parasymphyseal fractures
- symphyseal fractures (falling on chin; often goes along with bilateral condylar fractures)
- ascending ramus fractures
- diagnose with plain films or CT
- people with no teeth have dramatically remodeled bone; this increases risk of fracture and also makes plate revision much more difficult.
Orbital Blowout
Entrapment can follow orbital blow-out.
Signs and Symptoms
- history
- physical exam
History
History is tremendously important to uncover the story or mechanism of injury.
What hit their face? ie what part of the car?
Important symptoms incude:
- pain (location)
- facial weakness or numbness (facial nerve involvement)
- dipolopia, eye catching
- teeth meeting properly (descriminate from paresthesias: "does it feel like a piece of popcorn in your teeth?"
- neck pain
- nosebleed (blood, CSF)
Previous facial trauma
Physical Exam
tenderness
crepitus from fractures
palpation
orbit
nasal bone
maxilla: mideface stability (pull with thumb out from underneath front teeth)
inside jaw
teeth (ensure none loose)
investigate potentially damaged structures
CSF fluid rhinorrhea
epistaxis
hypoesthesia
obvious malposition: nose forehead
eyes: flame hemorrhage
septal hematoma in nose
look inside
ALWAYS examine the eye. Even if it is swollen shut
cranial nerve exam
- vision
- extraocular eye movements (look for entrapment)
- sensation
- facial expression
neck tenderness
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
CT scan is critical for diangosis, along with saggital reconstruction
Treatments
Hemorrhage
Local pressure
dressings and packing
reduction of facial fractures
endovascular consultation
ligation of vessels
tetanus prophylaxis; antibiotics should be given in cases of an open maxilla, and otherwise according to physician preference
Nasal fractures should be treated according to cosmetics.
within first 7 hours, or after 7 days. The interim is characterized by swelling, and normal anatomy
Consequences and Course
10% will have attendng C-spine fractures
50% with loss of consciouslness
Resources and References
Topic Development
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