Facial Trauma

Facial Trauma: Assessment - Face First Aid!

• Initial Approach: Follow ATLS principles (ABCDE). Prioritize airway, C-spine, breathing, circulation.
• Airway: Critical! Assess for obstruction (blood, foreign bodies, edema). Early intubation if GCS < 8, airway compromise, or expanding hematoma.
• Hemorrhage: Control active bleeding (direct pressure, packing). Consider angiography/embolization for persistent severe bleeding.
• Examination:
  • Systematic: Inspect (asymmetry, lacerations, ecchymosis), palpate (tenderness, crepitus, step-offs).
  • Neurological: GCS, cranial nerves (II, III, IV, V, VI, VII).
  • Ocular: Visual acuity, EOMs, diplopia, RAPD, globe integrity.
• Imaging: CT scan (non-contrast, thin-slice axial/coronal, 3D reconstruction) is gold standard.

⭐ Most common site of CSF leak in facial trauma: Cribriform plate (anterior cranial fossa).

Mandibular Fractures - Jaw Breakers United

Most common facial #2 fracture. Often multiple.

• Common Sites: 📌 Mnemonic: "Can Angry Birds Sing Melody?"
  • Condyle (30-35%)
  • Angle (20-25%)
  • Body (20-25%)
  • Symphysis/Parasymphysis (15-20%)
  • Ramus (<5%)
  • Coronoid process (<2%)
• Classification:
  • Simple/Compound/Comminuted.
  • Favorable/Unfavorable (muscle pull impact).
• Clinical Signs:
  • Pain, swelling, ecchymosis.
  • Malocclusion (💡 most reliable).
  • Trismus, step deformity.
  • Lower lip anesthesia (IAN injury).
  • Bleeding from ear (condylar #).

⭐ Muscle pull dictates displacement. Elevators (masseter, temporalis, med. pterygoid) pull superiorly/medially. Depressors (mylohyoid, geniohyoid, digastric) pull inferiorly/posteriorly. Lat. pterygoid pulls condyle anteromedially.

• Management:
  • Airway first.
  • Closed (MMF) or Open Reduction Internal Fixation (ORIF).

Midface Fractures - Central Face Carnage

• Le Fort Fractures: Classification of complex maxillary injuries.
  • 📌 Mnemonic: I = Palate floats; II = Maxilla floats (pyramidal); III = Face floats (craniofacial dysjunction).
  • Le Fort I (Transverse): Horizontal; palate separation, mobile palate, malocclusion.
  • Le Fort II (Pyramidal): Maxilla & nasal bones separation; mobile midface, infraorbital paresthesia, CSF rhinorrhea possible.
  • Le Fort III (Craniofacial Dysjunction): Midface-cranial base separation; gross edema, 'Dish face' deformity, CSF rhinorrhea, airway compromise. ⭐ > 'Dish face' deformity is characteristic of Le Fort III fractures.
• Clinical Differentiation (Le Fort Types):

• Zygomaticomaxillary Complex (ZMC) Fracture (Tripod/Tetrapod):
  • Involves: Frontozygomatic suture, zygomatic arch, infraorbital rim, zygomaticomaxillary buttress.
  • Signs: Cheek flattening, diplopia, trismus, subconjunctival hemorrhage, infraorbital anesthesia. fracture components diagram)
• Naso-Orbital-Ethmoid (NOE) Fracture:
  • Signs: Traumatic telecanthus (intercanthal distance > 35mm), flattened nasal dorsum, epiphora.
  • Crucial: Medial canthal tendon (MCT) integrity (Markowitz classification).

Orbito-Frontal Fractures - Eye & Brow Blows

• Orbital Fractures: Predominantly blowout or tripod types.
  • Blowout Fracture: Most common; inferior wall (floor) > medial wall.
    • Mechanism: Direct globe trauma → ↑intraorbital pressure.
    • Signs: Diplopia (esp. upgaze), enophthalmos, infraorbital nerve anesthesia (cheek/lip numbness), restricted eye movements (muscle entrapment), periorbital ecchymosis. "Teardrop sign" on CT.
  • Tripod (Zygomaticomaxillary Complex - ZMC) Fracture: Involves zygomatic arch, lateral orbital wall, inferior orbital rim, and zygomaticomaxillary buttress.
    • Signs: Malar flattening, palpable step-offs, trismus, diplopia.
• Frontal Sinus Fractures: Classified by anterior table, posterior table, or combined involvement; nasofrontal outflow tract (NFOT) status is key.
  • Anterior table: Primarily cosmetic (forehead depression).
  • Posterior table: ↑Risk of CSF leak, meningitis, intracranial injury.
  • NFOT injury: ↑Risk of mucocele/mucopyocele.
  • Management: Varies by displacement, table involvement, NFOT patency, and presence of CSF leak (observation, ORIF, obliteration, cranialization).

⭐ Critical signs indicating urgent surgical intervention for orbital fractures include: persistent diplopia in primary gaze, non-resolving oculocardiac reflex (bradycardia, nausea), "white-eyed blowout" (pediatric entrapment with minimal external signs), and significant enophthalmos (>2 mm).

High‑Yield Points - ⚡ Biggest Takeaways

• Le Fort fractures: I (floating palate), II (pyramidal), III (craniofacial dysjunction); assess maxillary mobility.
• Nasal bone fractures: Most common; closed reduction within 5-7 days for best results.
• Orbital blowout fractures: Cause diplopia, enophthalmos, infraorbital anesthesia; "teardrop" sign on CT.
• Mandibular fractures: Common at condyle/angle; malocclusion is a key diagnostic sign.
• ZMC fractures (tripod): Result in cheek flattening, trismus; assess ocular motility.
• CSF rhinorrhea with skull base fractures: Confirm using β2-transferrin test.
• Airway management is the top priority in severe facial trauma.