Module 5 - Head and Neck

Craniomaxillofacial Trauma

Etiology & Assessment


A. Etiology

  • In motor vehicle accidents (MVA's), injuries occur to the head, face and cervical spine in over 75% of all victims. Over 4,000,000 people are injured in MVA's each year in North America.
  • Other causes of craniomaxillofacial trauma include assaults, bicycle accidents, industrial accidents, and athletic accidents.
  • The incidence of different craniomaxillofacial trauma are as follows: Nasal>Mandible>Zygoma>Orbital>Complex

 

B. Initial Assessment

  • ABCs
  • Facial and other required X-rays
  • CT Scan
  • Appropriate referral when indicated

 

C. Emergency Treatment

I. Airway Difficulties

  • Facial fracture may impair ventilation
  • Bleeding and aspiration
  • Swelling, hematoma & edema
  • Avulsed and fractured teeth, dentures
  • Foreign materials
  • Treatment is to relieve obstruction, but if unsuccessful, cricothyroidotomy may be performed

II. Profuse Hemorrhage

  • May be from facial fractures or from lacerations
  • External bleeding

    > Controlled by direct pressure

  • Internal bleeding

    > Reduction of facial fractures

    > Anteroposterior nasal packing

    > Soft Wrap around facial compression

    > External carotid ligation

    > Blood replacement


III. Treatment of associated soft tissue injuries



D. Signs & Symptoms of Facial Fractures

  • Lacerations - intra- and extraoral
  • Deformity
  • Tenderness and pain
  • Crepitation from bony movement, SC emphysema
  • Numbness (CN V1, V2, V3)
  • Paralysis (CN VII), facial asymmetry
  • Malocclusion of teeth
  • Diplopia or decreased visual accuity
  • Nasopharyngeal bleeding
  • Mobility of facial bones

 

E. Glasgow Coma Scale

I. Best Verbal Response

  • None - 1
  • Incomprehensible sound - 2
  • Inappropriate words - 3
  • Confused - 4
  • Oriented - 5

II. Eyes Open

  • None - 1
  • To Pain - 2
  • To Speech - 3
  • Spontaneously - 4

III. Best Motor Response

  • None - 1
  • Abnormal Extension - 2
  • Abnormal Flexion - 3
  • Localizes Pain - 4
  • Obeys Commands - 5


F. Classification of Facial Fractures

  • Open vs. Closed
  • Anatomically (cranium, frontal sinus, orbital, zygomatic, orbitozygomatic, nasal, nasal-orbital-ethmoid, maxillary, mandibular)
  • Complex facial fractures are further classified into: Le Fort I, Le Fort II, Le Fort III, Le Fort IV, Pan Facial Smash


G. Radiographic Evaluation

Water's - PA oblique view for maxillary sinuses, maxilla, orbits zygomatic arches, nasal bones and nasal processes and mandible

Caldwell - PA (15o) frontal bone, orbital margins, ethmoids, FZ sutures, lateral maxillary walls

Lateral - Frontal sinus, orbital roofs and lateral facial bone view

PA & Lateral Oblique - Mandibular views showing symphasis, parasymphasis, body ramus, coronoid and condylar

Towne's - Condylar and subcondylar fractures

Panorex - Rotating X-ray tube shows entire mandible and lower maxilla

Others - F.O., optic foramen, nasal bone views, lateral anterior (arch), etc.

CT Scan - Essential in accurate preoperative evaluation of upper and mid facial fractures


H. Occlusal Assessment

  • Critical in evaluation of facial fractures
  • Helps determine whether there is displacement of fracture fragments or condylar subluxation/dislocation
  • Malocclusion can occur even if fractures are undisplaced


I. Definitive Treatment of Facial Fractures

  • Conservative - soft diet, analgesics
  • Closed reduction with no fixation or with external fixation
  • Open reduction with rigid or non-rigid fixation (or combination of both)
  • Primary assessment and care of the various fractures
  • Complete history and physical mandatory to rule out other injuries
  • Close observation of clinical findings

 

Author: Dr. R. Bendor-Samuel