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
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.