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Injuries to the Face 

  • Blunt trauma
    • More threatening as they are not immediately obvious and precise diagnosis is more difficult
    • Types – acceleration, deceleration, shearing, crushing, compression
    • E.g. assault, car crash, falls
  • Penetrating trauma
    • Wounds from impalement or object passing through
    • Severity is due to organ/tissue damage
    • High velocity (gun) and low velocity (knife)

Frontal sinus fractures

  • The frontal sinuses are contained in frontal bone and drain into middle meatus into the nasal cavity through nasofrontal ducts
  • They are absent at birth – post natally anterior ethmoidal cells invade the frontal bone and form the frontal sinus
    • Completely developed by the age of 15
  • Anatomic divisions
    • Sinus floor – orbital roof
    • Posterior table – anterior cranial fossa
    • Anterior table – frontal contour
  • Fractures occur from blunt trauma to the part of the frontal bone that overlies the sinus
  • Clinical features – upper face edema, ecchymosis, deformity of frontal bone, CSF rhinorrhea (indicates posterior table fracture)
  • Treatment
    • Anterior table fracture with no CSF leak – observation
    • Largely displaced/posterior table fractures/CSF leak – ORIF

Naso-orbital ethmoid (NOE) fractures

  • Occur due to high energy trauma to the mid-face e.g. motor vehicle accident
  • Involves the frontal process of maxilla, ethmoid bone, lacrimal bone and frontal bone
  • Most problematic to repair, often result in noticeable post-injury change in facial appearance
  • Classification is based on the status of central fragment and medial canthal tendon (MCT)
    • Markowitz and Manson Classification – (I) MCT is attached to the central fragment (II) MCT is attached to comminuted fragments (III) comminuted central fragment with avulsion of the MCT
  • Clinical features – telecanthus, loss of dorsal nasal projection, periorbital edema, subconjunctival haemorrhage
  • Treatment
    • If MCT is non-mobile – conservative, non-operative repair
    • If MCT is mobile/lax – ORIF

Nasal fractures

  • Most common fracture of facial bones
  • Clinical features – bruising, swelling, deformity, bleeding, difficulty breathing
    • Look for septal haematoma – needs to be drained if present as it can lead to ischemia of the septal cartilage and permanent necrosis
  • Examine external deformity and do intranasal exam
  • Closed reduction
    • Determine direction of displacement and mark direction of correction – as this can be obscured once local anaesthetic is injected
    • Inject septum intranasally and pack the nose with otrivin soaked packing for haemostasis
    • Place instrument in depressed side along the lateral wall of nose below the nasal frontal cartilage
    • Use finger and apply force to straighten where bent

Orbital fractures

  • The orbit consist of  7 bones
    • Frontal, sphenoid, zygomatic, maxilla, palatine, lacrimal and ethmoid bone

Types

  • Orbital rim fracture – affects the bony outer edges; commonly accompanied by optic nerve injuries
  • Blowout fracture – break in the floor or inner wall of the orbit
  • Orbital floor fracture – trauma to the orbital rim pushes the bones back, causing the floor to buckle downwards

Clinical features

  • Diplopia
  • Periorbital edema and ecchymosis
  • Subconjunctival hemorrhage

Investigations

  • Forced duction test – to assess passive motion of the globe and differentiate between neurological and mechanical restriction
  • Extra ocular muscle test
  • Imaging – XR, CT, MRI of orbit

Treatment

  • Defects <1cm don’t require operative treatment unless enophthalmos/diplopia last >2weeks
  • Surgery

Zygomatic complex fractures

  • Comprise of 3 types of fractures
    • Zygomatic arch
    • Inferior orbital rim
    • Lateral orbital rim
  • Results from a direct blow to the malar eminence

Clinical features

  • Flattening of the malar eminence
  • Infra-orbital paraesthesia – due to disruption of the infra-orbital nerve
  • Trimsus – due to impingement of the temporalis muscle

Treatment – closed or open reduction

Fracture of the middle third area

  • Includes fracture of the maxilla, zygoma and nasal bone
Le Fort Classification  
  • Type I – horizontal maxillary fracture, separating the teeth from the upper face
  • Type II – pyramidal fracture, with teeth at the pyramid base and nasofrontal suture at the apex
  • Type III – craniofacial disjunction

Clinical features

  • Facia edema, periorbital ecchymosis
  • Subconjunctival hemorrhage
  • Diplopia
  • Guerin sign – haematoma at the greater palatine foramen

Investigations

  • Ophthalmic exam
  • CT scan of the head
  • X-ray skull

Treatment

  • Ensure airway is patent – intubation or tracheostomy if required
  • Antibiotics
  • Associated zygoma and nasal fractures are reduced first
  • Fixation of teeth
  • Refer to specialist maxillofacial centre

Mandible fractures

 Location  

  • I – At the neck of the condyle
  • II – At the angle of the mandible
  • III – Near the mental foramen

Type of fracture

  • Simple
  • Compound
  • Comminuted
  • Pathological
  • Green stick

Clinical features

  • Pain and tenderness in the lower jaw
  • Coleman’s sign – haematoma at the floor of the mouth
  • Difficulty in opening the mouth, speech and swallowing
  • Paraethesia

Treatment

  • Antibiotics – to prevent osteomyelitis
  • Open fixation
  • Fluid diet – for 6 weeks
  • Irrigation of oral cavity to maintain oral hygiene
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