|
Facial Trauma
Facial trauma, also called maxillofacial trauma, is any
physical trauma to the face. Facial trauma can involve soft tissue
injuries such as burns, lacerations and bruises, or fractures of the
facial bones such as nasal fractures and fractures of the jaw, as well
as trauma such as eye injuries. Symptoms are specific to the type of
injury; for example, fractures may involve pain, swelling, loss of
function, or changes in the shape of facial structures.
Facial injuries have the potential to cause disfigurement and loss of
function; for example, blindness or difficulty moving the jaw can
result. Although it is seldom life-threatening, facial trauma can also
be deadly, because it can cause severe bleeding or interference with the
airway; thus a primary concern in treatment is ensuring that the airway
is open and not threatened so that the patient can breathe. Depending on
the type of facial injury, treatment may include bandaging and suturing
of open wounds, administration of ice, antibiotics and pain killers,
moving bones back into place, and surgery. When fractures are suspected,
radiography is used for diagnosis. Treatment may also be necessary for
other injuries such as traumatic brain injury, which commonly accompany
facial trauma.
In developed countries, the leading cause of facial trauma used to be
motor vehicle accidents, but this mechanism has been replaced by
interpersonal violence; however auto accidents still predominate as the
cause in developing countries and are still a major cause elsewhere.
Thus prevention efforts include awareness campaigns to educate the
public about safety measures such as seat belts and motorcycle helmets,
and laws to prevent drunk and unsafe driving. Other causes of facial
trauma include falls, industrial accidents, and sports injuries.
Classification
Soft tissue injuries include abrasions, lacerations, avulsions,
bruises, burns and cold injuries.
Commonly injured facial bones include the nasal bone (the nose), the
maxilla (the bone that forms the upper jaw), and the mandible (the lower
jaw). The mandible may be fractured at its symphysis, body, angle, ramus,
and condoyle. The zygoma (cheekbone) and the frontal bone (forehead) are
other sites for fractures. Fractures may also occur in the bones of the
palate and those that come together to form
the orbit of the eye.
At the beginning of the 20th century, René Le Fort mapped typical
locations for
facial fractures; these are now known as Le Fort I, II, and III
fractures ( Le Fort I fractures, also called Guérin or horizontal
maxillary fractures, involve the maxilla, separating it from the palate.
Le Fort II fractures, also called pyramidal fractures of the maxilla,
cross the nasal bones and the orbital rim. Le Fort III fractures, also
called craniofacial disjunction and transverse facial fractures, cross
the front of the maxilla and involve the lacrimal bone, the lamina
papyracea, and the orbital floor, and often involve the ethmoid bone.
are the most serious. Le Fort fractures, which account for 10–20% of
facial fractures, are often associated with other serious injuries. Le
Fort made his classifications based on work with cadaver skulls, and the
classification system has been criticized as imprecise and simplistic
since most midface fractures involve a combination of Le Fort fractures.
Although most facial fractures do not follow the patterns described by
Le Fort precisely, the system is still used to categorize injuries.
Causes
Injury mechanisms such as falls, assaults, sports injuries, and
vehicle crashes are common causes of facial trauma in children as well
as adults. Blunt assaults, blows from fists or objects, are a common
cause of facial injury. Facial trauma can also result from wartime
injuries such as gunshots and blasts. Animal attacks and work-related
injuries such as industrial accidents are other causes. Vehicular trauma
is one of the leading causes of facial injuries. Trauma commonly occurs
when the face strikes a part of the vehicle's interior, such as the
steering wheel. In addition, airbags can cause corneal abrasions and
lacerations (cuts) to the face when they deploy.
Signs and symptoms
Fractures of facial bones, like other fractures, may be associated
with pain, bruising, and swelling of the surrounding tissues (such
symptoms can occur in the absence of fractures as well). Fractures of
the nose, base of the skull, or maxilla may be associated with profuse
nosebleeds. Nasal fractures may be associated with deformity of the
nose, as well as swelling and bruising. Deformity in the face, for
example a sunken cheekbone or teeth which do not align properly,
suggests the presence of fractures. Asymmetry can suggest facial
fractures or damage to nerves. People with mandibular fractures often
have pain and difficulty opening their mouths and may have numbness in
the lip and chin. With Le Fort fractures, the midface may move relative
to the rest of the face or skull.
Diagnosis
Radiography, imaging of tissues using X-rays, is used to rule out
facial fractures. Angiography (X-rays taken of the inside of blood
vessels) can be used to locate the source of bleeding. However the
complex bones and tissues of the face can make it difficult to interpret
plain radiographs; CT scanning is better for detecting fractures and
examining soft tissues, and is often needed to determine whether surgery
is necessary, but it is more expensive and difficult to obtain. CT
scanning is usually considered to be more definitive and better at
detecting facial injuries than X-ray. CT scanning is especially likely
to be used in people with multiple injuries who need CT scans to assess
for other injuries anyway.
Prevention
Measures to reduce facial trauma include laws enforcing seat belt use
and public education to increase awareness about the importance of seat
belts and motorcycle helmets. Efforts to reduce drunk driving are other
preventative measures; changes to laws and their enforcement have been
proposed, as well as changes to societal attitudes toward the activity.
Information obtained from biomechanics studies can be used to design
automobiles with a view toward preventing facial injuries. While seat
belts reduce the number and severity of facial injuries that occur in
crashes, airbags alone are not very effective at preventing the
injuries. In sports, safety devices including helmets have been found to
reduce the risk of severe facial injury. Additional attachments such as
face guards may be added to sports helmets to prevent orofacial injury
(injury to the mouth or face).
Treatment
An immediate need in treatment is to ensure that the airway is open
and not threatened (for example by tissues or foreign objects), because
airway compromise can occur rapidly and insidiously, and is potentially
deadly. Material in the mouth that threatens the airway can be removed
manually or using a suction tool for that purpose, and supplemental
oxygen can be provided. Facial fractures that threaten to interfere with
the airway can be
 reduced
by moving the bones back into place; this both reduces bleeding and
moves the bone out of the way of the airway. Intubation (inserting a
tube into the airway to assist breathing) may be difficult or impossible
due to swelling. Nasal intubation, inserting an endotracheal tube
through the nose, may be contraindicated in the presence of facial
trauma because if there is an undiscovered fracture at the base of the
skull, the tube could be forced through it and into the brain. If facial
injuries prevent oraotracheal or nasotracheal intubation, a surgical
airway can be placed to provide an adequate airway. Although
cricothyrotomy and tracheostomy can secure an airway when other methods
fail, they are used only as a last resort because of potential
complications and the difficulty of the procedures.
A dressing can be placed over wounds to keep them clean and to
facilitate healing, and antibiotics may be used in cases where infection
is likely. People with contaminated wounds who have not been immunized
against tetanus within five years may be given a tetanus vaccination.
Lacerations may require stitches to stop bleeding and facilitate wound
healing with as little scarring as possible. Although it is not common
for bleeding from the maxillofacial region to be profuse enough to be
life threatening, it is still necessary to control such bleeding. Severe
bleeding occurs as the result of facial trauma in 1–11% of patients, and
the origin of this bleeding can be difficult to locate. Nasal packing
can be used to control nose bleeds and hematomas that may form on the
septum between the nostrils]
Such hematomas need to be drained. Mild nasal fractures need nothing
more than ice and pain killers, while breaks with severe deformities or
associated lacerations may need further treatment, such as moving the
bones back into alignment and antibiotic treatment.
Treatment aims to repair the face's natural bony architecture and to
leave as little apparent trace of the injury as possible. Fractures may
be repaired with metal plates and screws. They may also be wired into
place. Bone grafting is another option to repair the bone's
architecture, to fill out missing sections, and to provide structural
support. Medical literature suggests that early repair of facial
injuries, within hours or days, results in better outcomes for function
and appearance.
Specialists may be needed for specific aspects of facial trauma
treatment; these include otorhinolaryngologists, plastic surgeons, and
oral-maxillo-facial surgeons.
Prognosis and complications
By itself, facial trauma rarely presents a threat to life; however it
is often associated with dangerous injuries, and life-threatening
complications such as blockage of the airway may occur. The airway can
be blocked due to bleeding, swelling of surrounding tissues, or damage
to structures. Burns to the face can cause swelling of tissues and
thereby lead to airway blockage. Broken bones such as combinations of
nasal, maxillary, and mandibular fractures can interfere with the
airway. Blood from the face or mouth, if swallowed, can cause vomiting,
which can itself present a threat to the airway because it has the
potential to be aspirated.Since airway problems can occur late after the
initial injury, it is necessary for healthcare providers to monitor the
airway regularly.
Even when facial injuries are not life threatening, they have the
potential to cause disfigurement and disability, with long-term physical
and emotional results.Facial injuries can cause problems with eye, nose,
or jaw function and can threaten eyesight. As early as 400 BC,
Hippocrates is thought to have recorded a relationship between blunt
facial trauma and blindness. Injuries involving the eye or eyelid, such
as retrobulbar hemorrhage, can threaten eyesight; however, blindness
following facial trauma is not common.
Nerves and muscles may be trapped by broken bones; in these cases the
bones need to be put back into their proper places quickly. For example,
fractures of the orbital floor or medial orbital wall of the eye can
entrap the medial rectus or inferior rectus muscles. In facial wounds,
tear ducts and nerves of the face may be damaged. Fractures of the
frontal bone can interfere with the drainage of the frontal sinus and
can cause sinusitis.
Infection is another potential complication, for example when debris
is ground into an abrasion and remains there. Injuries resulting from
bites carry a high infection risk.
Epidemiology
As many as 50–70% of people who survive traffic accidents have facial
trauma. In most developed countries, violence from other people has
replaced vehicle collisions as the main cause of maxillofacial trauma;
however in many developing countries traffic accidents remain the major
cause. Increased use of seat belts and airbags has been credited with a
reduction in the incidence of maxillofacial trauma, but fractures of the
mandible (the jawbone) are not decreased by these protective measures.
The risk of maxillofacial trauma is decreased by a factor of two with
use of motorcycle helmets. A decline in facial bone fractures due to
vehicle accidents is thought to be due to seat belt and drunk driving
laws, strictly enforced speed limits and use of airbags. In vehicle
accidents, drivers and front seat passengers are at highest risk for
facial trauma.
Facial fractures are distributed in a fairly normal curve by age,
with a peak incidence occurring between ages 20 and 40, and children
under 12 suffering only 5–10% of all facial fractures. Most facial
trauma in children involves lacerations and soft tissue injuries. There
are several reasons for the lower incidence of facial fractures in
children: the face is smaller in relation to the rest of the head,
children are less often in some situations associated with facial
fractures such as occupational and motor vehicle hazards, there is a
lower proportion of cortical bone to cancellous bone in children's
faces, poorly developed sinuses make the bones stronger, and fat pads
provide protection for the facial bones.
Head and brain injuries are commonly associated with facial trauma,
particularly that of the upper face; brain injury occurs in 15–48% of
people with maxillofacial trauma. Coexisting injuries can affect
treatment of facial trauma; for example they may be emergent and need to
be treated before facial injuries. People with trauma above the level of
the collar bones are considered to be at high risk for cervical spine
injuries (spinal injuries in the neck) and special precautions must be
taken to avoid movement of the spine, which could worsen a spinal
injury.
|
