Maxillofacial Trauma

• Facial trauma presents a unique challenge to the EP. There is often a high level of concern by both the patient and practitioner because of the potential for permanent disfigurement.
• Maxillofacial trauma is often associated with other injuries especially to the head, neck and cervical spine. Pediatric patients have a higher rate of associated injuries than do adults. The dramatic nature of facial injuries should never distract the treating physician from the ABCs of resuscitation. In addition, delayed airway compromise must be anticipated.
• Even in the absence of life-threatening injuries, patients may have involvement of critical structures such as the globe, facial nerve and parotid duct. Examination must be methodical in order to determine the extent of injury.

• Most facial fractures do not cause airway compromise. However, patients with significant injury such as Le Fort II and III fractures should have initial care directed toward airway stabilization.
• CSF rhinorrhea and basilar skull fractures: Conservative measures to promote dural closure include bed rest, stool softeners, and head elevation. Prophylactic antibiotics are not indicated
• Hemorrhage: Except in children, life-threatening bleeding from facial trauma is rare. Control hemorrhage with direct pressure rather than clamping or suture ligation.
• Epistaxis: Usually stops spontaneously or with anterior packing. However, posterior epistaxis can occur and will require appropriate therapy (see "Nasal Emergencies").
• Broad-spectrum antibiotics are routine for facial fractures that extend into the tooth-bearing region. The use of prophylactic antibiotics for sinus fractures is controversial. It is recommended to coordinate care with the specialist providing definitive care.
• The majority of patients are discharged from the ED unless they have associated injuries that require admission. Prior to discharge, maxillofacial surgery should evaluate the patient in order to assess the stability of the injury as well as arrange for definitive care and follow-up.
• Patients should be given a prescription for analgesics prior to discharge.

• The nose is frequently fractured secondary to its anterior location on the face.
• Isolated nasal fractures are of little clinical consequence unless there is deformity or septal deviation that limits airflow through the nares.

• Patients present with nasal swelling, pain and epistaxis. They often complain of a nasal deformity. There will be a history of recent trauma.
• Examination: There is usually soft tissue swelling and ecchymosis unless the trauma is very recent. Patients may also have deformity/asymmetry, crepitus and overlying laceration. If there is a deformity, it is important to inquire whether this is old or new. The EP should check the patency of both nares and look intranasally for septal hematoma and foreign body. When present, epistaxis is usually mild and will resolve spontaneously. Posttraumatic clear nasal discharge is suspicious for cerebrospinal fluid rhinorrhea secondary to fracture of the cribriform plate.
• Diagnosis is made clinically. Nasal X-rays add little to the management and disposition.

• Persistent epistaxis is treated with nasal packing. If there is a significant laceration of the nasal mucosa, the patient is referred to ENT for consideration of suture repair.
• Any septal hematoma must be drained (see below).
• Indications for reduction of nasal fractures include deformity and naris obstruction. Fractures should be reduced by an ENT specialist. Most prefer to do the reduction after soft tissue swelling has resolved (3-7 days). The EP needs to arrange appropriate follow-up. Patients should be instructed to apply ice intermittently to reduce swelling. Prescribe analgesics as well as antibiotics if nasal packing has been placed.
• Septal hematoma: This manifests as asymmetry or widening of the nasal septum. There may be local discoloration although this unreliable as a means of diagnosis. If not adequately drained, the hematoma can become infected and cause subsequent necrosis and deformity of the septum. Hematomas are drained either via needle aspiration or incision. It is important to make sure that all blood has been expressed from the hematoma. After drainage, both nares are packed so that blood does not reaccumulate. These patients need antibiotics and close follow-up.

• NOE fractures are secondary to posterior forces directed at the midface and may involve the adjacent frontal bone and maxillary bone as well as the medial orbital wall, cribriform plate and anterior cranial fossa.
• These may be isolated injuries but are more likely to be associated with other trauma.

• Patients have findings as seen with nasal fracture (see above). Patients may also have CSF rhinorrhea, ocular injuries and telecanthus or widening of the space between the eyes secondary to laceration of the medial canthal tendon.
• CT is indicated in cases of suspected NOE fracture.

These injuries are a result of direct blunt trauma to the forehead. A significant amount of force is necessary to cause a frontal sinus fracture; always consider associated intracranial injury.

Clinical Presentation and Diagnosis

• Patients will have a history of direct trauma, often a motor vehicle accident in which their head struck the steering wheel or dash.
• Examination: Look for local swelling, deformity and overlying laceration. Patients may also have CSF rhinorrhea and palpable step-offs or crepitus. Not all fractures are clinically obvious.
• Diagnosis is made by CT scan.

• All frontal sinus fractures warrant evaluation by an appropriate specialist. In particular, patients with posterior wall fractures should be seen by a neurosurgeon. Mandible Fracture Mandible fractures are common injuries encountered by the EP. Many cases (>50%) involve fractures at more than one site.

• Patients complain of pain, dental malocclusion and difficulty opening or closing the mouth.
• Examination: Inspect for local tenderness, swelling and deformity. Patients may have facial asymmetry, lower lip anesthesia and difficulty opening and closing the mouth. Intra-oral examination often reveals lacerations, sublingual hematoma, dental trauma and obvious fracture with separation between the teeth. Subtle dental malocclusion is identified by the absence of a firm bite using a tongue blade placed between the teeth.
• Plain radiographs, panograph or the standard mandible series, confirm the diagnosis.

• Bilateral mandible fractures can result in airway obstruction secondary to tongue displacement. The first priority is always to provide an adequate airway if necessary.
• Prompt fixation is desired. Make sure that close oral surgery follow-up is arranged.

• The zygoma articulates with multiple other bones and forms a significant part of both the orbit and the maxillary sinus.
• Most zygoma fractures are complex and involve these adjacent structures. Clinical Presentation and Diagnosis
• Patients complain of difficulty and pain with mouth opening. Diplopia is possible with fractures involving the orbit and extraocular muscle entrapment.
• Examination: Findings include facial deformity, edema, ecchymosis, epistaxis, infraorbital/ upper lip anesthesia, subcutaneous emphysema and subconjunctival hemorrhage of the lateral aspect of the eye. Always evaluate for associated globe injury.
• Suspected complex fractures should be evaluated with CT scan. Isolated arch fractures are visualized by a submentovertex radiograph.

The Le Fort classification consists of three fracture patterns and was developed to describe midface and maxilla fractures. However, the majority of these fractures are actually much more complex and do not conform to any one type.

Clinical Presentation and Diagnosis

• These fractures present with significant facial swelling that may obscure underlying deformity. Other possible findings include epistaxis, CSF rhinorrhea, dental malocclusion, infraorbital/upper lip anesthesia and globe injury.
• Le Fort II and III fractures can cause airway compromise and are often associated with intracranial injury.
• Diagnosis is via CT scan.

Temporomandibular joint (TMJ) dislocation is most often bilateral. Dislocation occurs when the mandibular condyle is displaced anterior to the articular surface; muscle spasm often precludes spontaneous reduction.

Etiology

• Includes blunt trauma, seizure, extrapyramidal reaction and wide opening of the mouth as occurs with yawning. Many patients have underlying hypermobility of the joint.

Classification	Fracture Pattern
Le Fort I	Horizontal fracture across the maxilla above the hard palate. Mobile maxilla and palate on exam (nasal bridge remains stable).
Le Fort II	AKA pyramidal fracture Fracture through the maxilla extending to the medial orbit and over the nasal bridge. Mobility of the maxilla and nasal bridge as a unit. May have obvious nasal flattening.
Le Fort III	AKA craniofacial disjunction or "dishface" Fracture through the nasal bridge, orbits and frontozygomatic suture. Total mobility of the face including the zygoma and orbits.

Clinical Presentation and Diagnosis

• Patients present with significant pain and may describe trauma or other preceding event that involves wide mouth opening.
• Examination: The mouth is held open and can’t be closed. In unilateral dislocations, the jaw will be deviated towards the contralateral side (in contrast to condylar fractures). Patients will have difficulty speaking and swallowing.
• Diagnosis may be made clinically in most cases. However, X-ray evaluation is necessary in cases of trauma in order to rule out associated fracture.

• The ease of reduction depends upon when the dislocation occurred. Dislocations present for hours or more often require general anesthesia for reduction.
• Reduction is facilitated with IV muscle relaxants and/or local anesthesia.
• The physician’s hands are gloved and the thumbs placed inside the patient’s mouth on the posterior molars or alveolar ridge. The thumbs should be wrapped in gauze to protect from bite injury. The rest of the fingers wrap around the mandibular symphysis.
• Downward pressure is applied to unlock the condyle and the condyle then relocated with posterior pressure.
• In bilateral dislocations, reduction of one side at a time may be easier.
• The mandible is then stabilized with an Ace bandage wrapped around the jaw and head.

• Pain is usually well controlled with NSAIDs.
• Patients should be given follow-up with an oral surgeon and instructions for a soft diet.

Many of the same principles for wound care on the body also apply to the face (i.e., wound preparation, tetanus update). However, because of the aesthetic importance of this area, these principles must be stringently followed. In addition, there are some differences and special circumstances to consider when dealing with soft tissue injuries of the face and scalp. Specific anatomical areas are discussed below.

• Simple facial lacerations are closed with 6-0 nonabsorbable interrupted sutures after proper wound preparation. For complex wounds and wounds under tension, a layered repair with absorbable sutures may be necessary. Suture removal is in 3-5 days.
• The face is very vascular and, as a result, has rapid healing and less chance of wound infection. Clean facial wounds may be closed up to 24 hours after injury. In addition, debridement is kept to a minimum. Even questionable skin flaps often have adequate blood supply and acceptable healing.
• Lidocaine 1% with 1:100,000 epinephrine is appropriate in most cases and will assist in hemostasis. However, avoid use of epinephrine containing solutions on the ears, nose and tarsal plate. Consider regional nerve blocks for the tongue, ear, large wounds or when distortion of the tissues must be avoided (i.e., lips).
• Examination must assess those structures that have critical functions such as the facial nerve, parotid duct and muscles of facial expression.
• Prophylactic antibiotics haven’t been proven to decrease infection in routine wounds and aren’t indicated. Obvious exceptions include significant time elapsed since injury (>24 h), presence of foreign body, bite injuries, etc.
• NEVER hesitate to involve plastic surgery or ENT for repair. Cases in which this is indicated include:
  • Lacerations that involve critical structures such as the facial nerve.
  • Avulsion injuries or those with soft tissue defects.
  • Complicated anatomical location such as the ear, auditory canal, nasal alae, etc.
  • Complex lacerations with potential for poor aesthetic outcome.

• When exploring scalp wounds, take notice of any bony step-offs or galeal tears.
• Galeal defects must be repaired in order to avoid subgaleal hematomas and a depressed scar. Use 4-0 absorbable suture material.
• Skin is approximated with staples or nylon. Leave long tails on the suture to facilitate removal from within the hair.
• Consider a pressure dressing in large lacerations to reduce hematoma formation
• Remove sutures in 7-10 days. Forehead
• Maintain important landmarks including the scalp line, expressive wrinkles and eyebrows. Make sure that these are the first sutures placed during the superficial skin closure.
• U-shaped flap lacerations, especially with the base of the flap superiorly positioned, have a tendency to form a "trap-door" scar (the flap forms a prominent raised area). Careful deep tissue approximation is required and a compression dressing should be applied. Patients should be warned that future scar revision might be necessary.

• Never shave the eyebrow. It provides alignment and the shaved area may not grow back completely.
• If tissue excision is necessary, excise at an angle parallel to the shaft of the hair to avoid creating bald areas. Eyelid Lacerations
• See Ophthalmologic Emergencies.

• Simple lacerations of the ear are closed with 6-0 nonabsorbable suture.
• Wounds with exposed cartilage require detailed attention. Cartilage must be completely covered by skin in order to prevent subsequent infection and deformity. Cartilage may be conservatively trimmed to allow proper closure. In addition, devitalized cartilage should be debrided.
• Cartilage lacerations do not require reapproximation unless the fragments are unstable or displaced. In these cases, use 5-0 absorbable material and include the perichondrium in the repair.
• After repair, place the ear in a compression dressing with posterior and interior support.
• Otohematoma: Like septal hematomas of the nose, these require drainage in order to prevent necrosis of the underlying cartilage and subsequent deformity. Drainage is accomplished either with needle aspiration or incision. Afterwards, a compression dressing is placed to prevent reaccumulation of fluid. Close follow-up is mandatory.

• Simple wounds can be closed with either steri-strips or 6-0 nonabsorbable interrupted sutures.
• Complex wounds include those that involve cartilage and/or mucosa. Cartilage does not require suture repair unless there is displacement or instability of the fragments. In these cases, repair is done with fine absorbable suture. Mucosa is approximated with 5-0 absorbable suture with the knotted ends facing into the cavity of the naris. ENT repair of these complex lacerations is recommended. Also consider ENT repair for those wounds that involve the alae and free rim of the nostril since precise approximation is required.
• Examine for septal hematomas in all nasal trauma.

• All lip lacerations require a search for embedded dental foreign bodies as these retained elements greatly increase the risk of wound infection.
• The vermilion border is the landmark for repair of lip lacerations. Any wound involving the vermilion border requires meticulous placement of the first percutaneous stitch at that point in order to maintain proper alignment.
• Through-and-through lacerations of the lip are repaired in layers. The oral mucosa is closed first with 4-0 or 5-0 absorbable suture in order to minimize flow of saliva to the remainder of the wound. Subsequently, the deeper muscle layer is closed with 4-0 or 5-0 absorbable then the skin with 6-0 nonabsorbable material. Absorbable material may also be used for percutaneous lip closure and will avoid the trauma of suture removal that might occur in certain patients including children.
• Up to 30% of tissue loss is tolerated without significant resultant deformity.

• Most isolated oral mucosal lesions heal well without repair. The exceptions are deep wounds that may trap food and wounds that are caught between the teeth during chewing. Note the contrast to through-and-through wounds where the intraoral component must be repaired in order to minimize salivary contamination of the extraoral area.
• Repair of tongue lacerations can be controversial. Some general rules apply.
• Linear, superficial lacerations of the central tongue heal well without suturing.
• Lacerations which involve the edge, form flaps, bisect the tongue, or bleed excessively require suturing. An inadequate or ignored repair mayresult in loss of function and food trapping.
• When repair is required, use 4-0 or 5-0 absorbable and close all layers in a single stitch. Through-and-through lacerations are closed on both sides placing the suture through half the thickness of the wound. Sutures should be loose since the tongue may exhibit significant swelling after injury.
• Saline or hydrogen peroxide mouth rinses for intra-oral lacerations should be encouraged.