Introduction

Injuries to the face are common but the majority is relatively minor. A few are major and complex, requiring exacting tech­nique and infinite care in management. It must be remem­bered always that an intact and unscarred face is important to the well-being of the individual, and thus all injuries, however trivial, should be treated thoughtfully and sympathetically, with every effort always to produce an optimal outcome. In addition, even trivial blows to the face may:

cause injuries which compromise the airway;

directly or indirectly cause a head injury (a fall to the ground so banging the head, for instance);

cause injuries to the cervical spine.

Injuries to the face and facial bones result from both sport­ing activities and accidents, and intentional violence. The major injuries in the past were as a result of road traffic acci­dents, but the compulsory wearing of seat belts, car air bags, head restraints and laminated windscreens have reduced all of these greatly. However, the reduction in damage from this source has been almost matched by the increase in deliberate injury from bodily violence where ‘putting the boot in’ has become a fashion with appalling results.

Clinical effects

The mouth and nasal passages are the upper airway, and lacerations and fractures of the facial skeleton may give rise to immediate or delayed respiratory obstruction. Immediate obstruction may arise from inhalation of tooth fragments, accumulation of blood and secretions, and loss of control of the tongue in the unconscious or semiconscious patient. To avoid this, the patient should always be nursed in the semi-prone position (Fig. 38.1) with the head supported on the bent arm, and never lying on their back. Damaged teeth, blood and secretions can then fall out of the mouth and gravity pulls the tongue forward. As the patient is manoeuvred into the correct nursing position, the neck should be supported and held in a neutral position — a protective collar is advisable until a fracture of the cervical spine has been excluded. Under no circumstances should the chin be pulled up to straighten the airway. An intracranial injury should always be considered as a possibility, however minor the injury to the face.

Initial haemorrhage after a facial injury can be dramatic. Sustained bleeding is unusual but emergency surgery to stabilise the facial fractures and control bleeding may be required. The most likely causes of circulatory failure in a bad facial injury are accompanying skeletal injuries or a ruptured viscus, and these should always be actively sought for in the shocked patient. Oedema is a particular feature of all fractures of the facia skeleton and tends to develop within 60—90 minutes. Thus, patient with a shattered face may appear to have a choke airway immediately after the blow, but that airway may rapidly change and become occluded by swelling of the tongue  facial and pharyngeal tissues. This problem must always be borne in mind when the middle third of the face is involved, In Le Fort III fractures (see below) the facial bones may be thrust downwards and backwards along the base of the skull. As it does so, the posterior teeth of the upper and lower jaw contact first and the mouth is held open giving the impression of a good airway (Fig. 38.2). As swelling supervenes, the soft palate and the tongue may swell to meet, so closing the pharyngeal airway and leading to acute respiratory obstruction (Fig. 38.3). Whenever this is suspected, the ‘golden hour’ must be used to insert an oropharyngeal airway, even though the patient may appear conscious and unobstructed. If this is not done an emergency tracheostomy may have to be undertaken later with great risk to the patient.

Examination of the injuries

The examination of the patient should be under a good light with consideration of the airway and other collateral injuries always in mind. It is easy to be deviated from examining the whole patient by the dramatic effects of the facial injury. The rapid onset of oedema may make the examination of the face and routine head injury observations difficult — occasionally it is impossible to prise the eyelids apart to examine the pupil, for instance. Lacerations should be explored gently first and, if necessary, cleaned using sterile saline, aqueous antiseptic solution and/or dilute hydrogen peroxide.

Once the pattern and extent of soft-tissue injury has been established, attention should be given to the hard tissues. Regardless of the apparent site of the injury, the whole head should be examined visually and by palpation starting with the vault of the skull. A blow to the face may result in the head being thrown back against a hard object and a bruise or laceration on the occiput missed. The face should be examined from in front. Any asymmetry and displacements should be noted, although oedema may make this difficult. Gentle palpation, using both hands and wearing surgical gloves, gives the most information in searching for step deformities. Tenderness over sites of known weakness and potential for fracture (see below) is a very good guide for the possibility of fracture of the bone beneath. A suitable system is to examine from above downwards — the supraorbital and infraorbital ridges, the nasal bridge, the zygomas, including the zygomatic arch. The mandible should then be examined starting at the condyles bilaterally and then following the posterior and lower border of the mandible as far as the midline. All middle third injuries are accompanied by bleeding from the nose, and Le Fort II and III injuries frequently have a cerebrospinal fluid (CSF) leak with anterior or posterior CSF rhinorrhoea. All fractures of the maxilla lead to mucosal tears with bleeding from the nose. A particularly useful sign in the fractured zygoma is the frequent subconjuctival haemorrhage which will be found to have no posterior border when the patient is asked to look to the opposite side (Fig. 38.4). This gives a positive indication of a fracture of the bone behind.

The patient should then be examined intra orally with good illumination; a pen torch is insufficient. The lips should be parted and the occlusion of the teeth examined. The upper and lower teeth normally ‘fit’ together even if the occlusion is naturally irregular if they do not a fracture of the jaws is likely. All fractures of the alveolus (the bone holding the teeth) tear the gingiva and are compound into the mouth: the examiner should look for sites of bleeding. A haematoma in the floor of the mouth is a good indication of a fracture of the mandible, particularly in the edentulous case. The cheeks, throat and tongue should be examined at the same time. Movement of the jaw should be tested deviation from the midline at rest or on opening suggests a fracture of the side to which the jaw is deviating.

If a fracture of the maxilla is suspected, the upper dental arch should be grasped between index finger and thumb of one hand in the molar region, while the other is placed on the forehead. A gentle pull on the maxilla forward and backward, or side to side, will reveal movement between the examining hands. With the mandible, gentle manipulation across the suspected site of a fracture will confirm the presence of the fracture if ‘spinging’ is felt and seen. Confirmation of a fractured zygoma may be made by palpating the fractured antral wall above the upper molar teeth in the buccal sulcus.

The facial examination should be completed by testing for sensation over the face. Anaesthesia or parasthesia suggests a fracture proximally along the path of the nerve. Thus, anaesthesia of the cheek and upper lip suggests a fracture going through the infraorbital foramen, while anaesthesia of the lower lip suggests a fracture of the mandibular body. It is important to confirm that the patient has sight in both eyes. This may be difficult in the very oedematous patient with circumorbital haematoma, but a pen torch shone through the lids will confirm that the optic nerve is intact. Where possible, vision should be checked for diplopia by asking the patient to follow the light of the pen torch in both central and extremes of gaze. Diplopia may mean that there is damage to the thin orbital plates of bone, particularly the infraorbital plate.

All findings should be recorded accurately, preferably with diagrams to include measurements of lacerations and displacements. Photographs of the initial injury can be very helpful if litigation is likely to follow.

Investigations

Blood tests

Baseline full blood picture and serum electrolytes should be recorded, and the blood should be grouped when it is thought that much bleeding has occurred and more bleeding is likely.

Radiographs

Posteroanterior occipitomental radiographs taken at 10 and 30degree are the best initial radiographs to illustrate the site and displacement of the maxilla; an opaque antrum is a good indi­cation that there may be a fracture of the maxilla. A panoramic oral radiograph (orthopantomogram) is the radiograph of choice for the mandible as it shows the whole bone from condyle to condyle. If the patient cannot be positioned in the machines to achieve these views, radiographs should wait until the patient is fit enough. Poor radiographs can be misleading, and treatment can only be carried out on good ones. The orbital floor may be visualised best by a computerised tomography (CT) scan in the coronal plane, and may also be used to identify the presence and site of other middle third fractures. If a CT scan is to be made, always consider including the upper cervical spine in addition to the face.