Facial trauma, also called maxillofacial trauma, is any physicaltrauma to the face. Facial trauma can involve soft tissue injuriessuch as burns, lacerations and bruises, or fractures of the facialbones such as nasal fractures and fractures of the jaw, as well astrauma such as eye injuries. Symptoms are specific to the type ofinjury; for example, fractures may involve pain, swelling, loss offunction, or changes in the shape of facial structures.Facial injuries have the potential to cause disfigurement and loss offunction; for example, blindness or difficulty moving the jaw canresult. Although it is seldom life-threatening, facial trauma can alsobe deadly, because it can cause severe bleeding or interference withthe airway; thus a primary concern in treatment is ensuring that theairway is open and not threatened so that the patient can breathe.Depending on the type of facial injury, treatment may includebandaging and suturing of open wounds, administration of ice,antibiotics and pain killers, moving bones back into place, andsurgery. When fractures are suspected, radiography is used fordiagnosis. Treatment may also be necessary for other injuries suchas traumatic brain injury, which commonly accompany severe facialtrauma.
In developed countries, the leading cause of facial trauma used tobe motor vehicle accidents, but this mechanism has been replacedby interpersonal violence; however auto accidents still predominateas the cause in developing countries and are still a major causeelsewhere. Thus prevention efforts include awareness campaigns toeducate the public about safety measures such as seat belts andmotorcycle helmets, and laws to prevent drunk and unsafe driving.Other causes of facial trauma include falls, industrial accidents, andsports injuries.ClassificationSoft 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) andthe frontal bone (forehead) are other sites for fractures. Fracturesmay also occur in the bones of the palate and those that cometogether to form the orbit of the eye.
At the beginning of the 20th century, René Le Fort mapped typicallocations for facial fractures; these are now known as Le Fort I, II,and III fractures (right). Le Fort I fractures, also called Guérin orhorizontal maxillary fractures, involve the maxilla, separating it fromthe palate. Le Fort II fractures, also called pyramidal fractures of themaxilla, cross the nasal bones and the orbital rim. Le Fort IIIfractures, also called craniofacial disjunction and transverse facialfractures, cross the front of the maxilla and involve the lacrimalbone, the lamina papyracea, and the orbital floor, and often involvethe ethmoid bone. are the most serious. Le Fort fractures, whichaccount for 10–20% of facial fractures, are often associated withother serious injuries. Le Fort made his classifications based onwork with cadaver skulls, and the classification system has beencriticized as imprecise and simplistic since most midface fracturesinvolve a combination of Le Fort fractures. Although most facialfractures do not follow the patterns described by Le Fort precisely,the system is still used to categorize injuries.
CausesInjury mechanisms such as falls, assaults, sports injuries, andvehicle crashes are common causes of facial trauma in children aswell as adults. Blunt assaults, blows from fists or objects, are acommon cause of facial injury. Facial trauma can also result fromwartime injuries such as gunshots and blasts. Animal attacks andwork-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 thevehicles interior, such as the steering wheel. In addition, airbagscan cause corneal abrasions and lacerations (cuts) to the face whenthey deploy.Fractures of facial bones, like other fractures, may be associatedwith pain, bruising, and swelling of the surrounding tissues (suchsymptoms can occur in the absence of fractures as well). Fracturesof the nose, base of the skull, or maxilla may be associated withprofuse nosebleeds. Nasal fractures may be associated withdeformity of the nose, as well as swelling and bruising. Deformity inthe face, for example a sunken cheekbone or teeth which do notalign properly, suggests the presence of fractures.
Asymmetry can suggest facial fractures or damage to nerves.People with mandibular fractures often have pain and difficultyopening their mouths and may have numbness in the lip and chin.With Le Fort fractures, the midface may move relative to the rest ofthe face or skull.DiagnosisRadiography, imaging of tissues using X-rays, is used to rule outfacial fractures. Angiography (X-rays taken of the inside of bloodvessels) can be used to locate the source of bleeding. However thecomplex bones and tissues of the face can make it difficult tointerpret plain radiographs; CT scanning is better for detectingfractures and examining soft tissues, and is often needed todetermine whether surgery is necessary, but it is more expensiveand difficult to obtain. CT scanning is usually considered to be moredefinitive and better at detecting facial injuries than X-ray. CTscanning is especially likely to be used in people with multipleinjuries who need CT scans to assess for other injuries anyway.
PreventionMeasures to reduce facial trauma include laws enforcing seat beltuse and public education to increase awareness about theimportance of seat belts and motorcycle helmets. Efforts to reducedrunk driving are other preventative measures; changes to laws andtheir enforcement have been proposed, as well as changes tosocietal attitudes toward the activity. Information obtained frombiomechanics studies can be used to design automobiles with aview toward preventing facial injuries. While seat belts reduce thenumber and severity of facial injuries that occur in crashes, airbagsalone are not very effective at preventing the injuries. In sports,safety devices including helmets have been found to reduce the riskof severe facial injury. Additional attachments such as face guardsmay be added to sports helmets to prevent orofacial injury (injury tothe mouth or face). Mouth guards also used.TreatmentAn immediate need in treatment is to ensure that the airway is openand not threatened (for example by tissues or foreign objects),because airway compromise can occur rapidly and insidiously, andis potentially deadly.
Material in the mouth that threatens the airway can be removedmanually or using a suction tool for that purpose, and supplementaloxygen can be provided. Facial fractures that threaten to interferewith the airway can be reduced by moving the bones back intoplace; this both reduces bleeding and moves the bone out of theway of the airway. Tracheal intubation (inserting a tube into theairway to assist breathing) may be difficult or impossible due toswelling. Nasal intubation, inserting an endotracheal tube throughthe nose, may be contraindicated in the presence of facial traumabecause 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 injuriesprevent oraotracheal or nasotracheal intubation, a surgical airwaycan be placed to provide an adequate airway. Althoughcricothyrotomy and tracheostomy can secure an airway when othermethods fail, they are used only as a last resort because of potentialcomplications and the difficulty of the procedures.A dressing can be placed over wounds to keep them clean and tofacilitate healing, and antibiotics may be used in cases whereinfection is likely.
People with contaminated wounds who have not been immunizedagainst tetanus within five years may be given a tetanus vaccination.Lacerations may require stitches to stop bleeding and facilitatewound healing with as little scarring as possible. Although it is notcommon for bleeding from the maxillofacial region to be profuseenough to be life threatening, it is still necessary to control suchbleeding. Severe bleeding occurs as the result of facial trauma in 1–11% of patients, and the origin of this bleeding can be difficult tolocate. Nasal packing can be used to control nose bleeds andhematomas that may form on the septum between the nostrils. Suchhematomas need to be drained. Mild nasal fractures need nothingmore than ice and pain killers, while breaks with severe deformitiesor associated lacerations may need further treatment, such asmoving the bones back into alignment and antibiotic treatment.Treatment aims to repair the faces natural bony architecture and toleave as little apparent trace of the injury as possible. Fractures maybe repaired with metal plates and screws. They may also be wiredinto place. Bone grafting is another option to repair the bonesarchitecture, to fill out missing sections, and to provide structuralsupport.
Medical literature suggests that early repair of facial injuries, withinhours or days, results in better outcomes for function andappearance.Surgical specialists who commonly treat specific aspects of facialtrauma are oral and maxillofacial surgeons. These surgeons aretrained in the comprehensive management of trauma to the lower,middle and upper face and have to take written and oral boardexaminations covering the management of facial injuries.
Prognosis and complicationsBy itself, facial trauma rarely presents a threat to life; however it isoften associated with dangerous injuries and life-threateningcomplications such as blockage of the airway may occur. The airwaycan be blocked due to bleeding, swelling of surrounding tissues, ordamage to structures. Burns to the face can cause swelling oftissues and thereby lead to airway blockage. Broken bones such ascombinations of nasal, maxillary, and mandibular fractures caninterfere with the airway Blood from the face or mouth, if swallowed,can cause vomiting, which can itself present a threat to the airwaybecause it has the potential to be aspirated. Since airway problemscan occur late after the initial injury, it is necessary for healthcareproviders to monitor the airway regularly.Even when facial injuries are not life threatening, they have thepotential to cause disfigurement and disability, with long-termphysical and emotional results. Facial injuries can cause problemswith eye, nose, or jaw function and can threaten eyesight.
As early as 400 BC, Hippocrates is thought to have recorded arelationship between blunt facial trauma and blindness. Injuriesinvolving the eye or eyelid, such as retrobulbar hemorrhage, canthreaten eyesight; however, blindness following facial trauma is notcommon.Nerves and muscles may be trapped by broken bones; in thesecases the bones need to be put back into their proper placesquickly. For example, fractures of the orbital floor or medial orbitalwall of the eye can entrap the medial rectus or inferior rectusmuscles. In facial wounds, tear ducts and nerves of the face may bedamaged. Fractures of the frontal bone can interfere with thedrainage of the frontal sinus and can cause sinusitis.Infection is another potential complication, for example when debrisis ground into an abrasion and remains there. Injuries resulting frombites carry a high infection risk.
POSTED BY ATTORNEY RENE G. GARCIA:For more information:- Some of our clients have suffered this kindof injuries due to a serious accident. The Garcia Law Firm, P.C.was able to successfully handle these types of cases. For a freeconsultation please call us at 1-866- SCAFFOLD or 212-725-1313. http://en.wikipedia.org/wiki/Facial_trauma
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