Maxillofacial trauma

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
• 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

Exam

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 fx) or malar prominence flattening (zygoma fx)
• Acuity
• Diplopia
  • Binocular diplopia suggests entrapment of EOM
  • Monocular diplopia suggets lens dislocation
• Extraocular motion
  • Limitation on upward gaze occurs w/ fx 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 pts w/ exophthalmos, afferent nerve defect or e/o retrobulbar hematoma
• Fat through wound = septal perforation
• Raccoon eyes

Nose

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

Ears

• Auricular Hematoma
• CSF leak
• Hemotympanum
• Battle Sign

Oral

• Intraoral palpation of zygomatic arch to distinguish bony from soft tissue injury
• Mandible Fracture
  • Place finger in auditory canal while pt opens and closes jaw to detect condyle fx
  • Tongue blade test
    • 95% Sn for no fx if can bite down hard enough to break it when twisted by examiner
  • Jaw deviation due to mandible dislocation or condyle fx
    • Chin will point away from dislocation, towards a fracture
• Malocclusion occurs in mandible, zygomatic, and Le Fort fx
• Lacerations and mucosal ecchymosis suggests mandible fx

DDx

• Frontal Sinus Fracture
• Naso-Ethmoid Fracture
• Nasal Fracture
• Zygomatic Arch Fracture
• Zygomaticomaxillary (Tripod) Fracture
• Orbital Fracture
• Mandible Fracture
• Le Fort Fractures
• Dental Problems
• Skull Fracture

Imaging

• Suspect midface fx > facial CT
• Suspect orbital floor fx > orbital CT
• Suspect mandibular Fx
  • Mandibular series
    • Body fx > oblique view
    • Angle/symphysis fx > PA view
    • Condyle fx > AP axial (Towne's) view
• Plain Films
  • Water's view
    • Orbital rims/floors, zygmatic arch, maxillary sinus, maxilla
  • Bucket handle view
    • zygomatic arches

Pediatric Considerations

• Cricothyrotomy is contraindicated in pts <8yr old
• Maxillary sinuses do not develop until 6 yr old (reduces midfacial fx)
• Pediatric orbital floor is more pliable, more likely to lead to entrapment
• Mandible fx requires prompt referral (1-2d) due to rapid bone remodeling

Disposition

1. Bedside consult is necessary for:
   1. Decreased vision
   2. Tripod Fracture
   3. Le Fort Fracture
   4. Open Mandibular Fracture
   5. Frontal Sinus Fractures with intracranial involvement

See Also

• Head Trauma (Main)

Source

Tintinalli's