Facial trauma

1. Facial Trauma
Plastic & Reconstructive Surgery Department
SCGH
Dr Ranjit Kunchur
Dr Mike O’Hallaren
Dr Guy Watts

2. Aims
To relate the ABCDEs of Trauma to facial trauma patients
Early Plastic Surgery referral
Examination pearls
Suggested Investigations & Early Management

3. First things, first……
ABCDEs
Airway, with cervical spine support
Breathing & Ventilation
Circulation with control of bleeding sites
Deficit – Neurological
Exposure with environment control + Eyes, eyes, eyes…..
Therefore, do not miss the brain, eyes and C spine

4. EMST
ABCDEs

5. ABCDEs in facial trauma
Airway with C Spine
C Spine injury should be suspected in all patients with an altered level of consciousness, multi system trauma or blunt trauma
above the clavicle
Airway issues may result in
- Bilateral fracture of the anterior mandible
- Posterior inferior displacement of a fractured maxilla along the inclined skull base plane
- Loose teeth, bone fragments, vomitus, foreign bodies
- Bleeding (nasal or oral)
- Soft tissue edema
- Trauma to the larynx/trachea

6. ABCDEs in facial trauma
Bilateral fracture of the anterior mandible

7. ABCDEs in facial trauma
Posterior inferior displacement of a fractured maxilla along the inclined skull base plane

8. ABCDEs in facial trauma
Circulation with control of bleeding sites
- Life threatening bleeding is rare in isolated facial fractures (1 – 1.5%)
- Most common troublesome bleeding if from the nose
- Mostly controlled with patient positioning and direct pressure

9. ABCDEs in facial trauma
Circulation with control of bleeding sites
- Use Co-Phenylcaine + Good Visualization + Cotton soeked with vasoconstrictor/Cauterization with Silver Nitrate solution
- Merocel sponge
- Anterior nasal pack
- Posterior nasal pack
- Pressure balloon
Arteriogram + Embolization/Ligation

10. ABCDEs in facial trauma
Neurological
- Higher the level of the injury, greater the chance of neurological injury
- Watch for CSF Rhinorrhoea or Otorrhoea

11. ABCDEs in facial trauma
Neurological
CSF Rhinorrhoea
- Nasal drip with “Tram line” on face, “Double Halo” on cotton gauze
- Salty/Metallic taste
- Glucose test (>30mg/dl)

12. ABCDEs in facial trauma
Neurological
CSF Otorrhoea, Haemotympanum and the “Battle Sign”

13. ABCDEs in facial trauma
Eyes
From the obvious……

14. ABCDEs in facial trauma
Eyes
……to the subtle

15. ABCDEs in facial trauma
Eyes
Cardinal examination components include,
- Inspection (Circumorbital ecchymoses + Subconjunctival haematoma)
- Visual acuity
- Eye movements (Cranial Nerves III, IV & VI), entrapment and diplopia
- Pupillary reflexes (Cranial Nerves II & III)
Request Opthamology review early

16. Examination Pearls
Top to bottom - Out to in
Inspection
- Facial elongation, asymmetry, swelling
- Lacerations, abrasions, bleeding
- Cranial Nerve VII

17. Examination Pearls
Top to bottom - Out to in
Palpation
- Tenderness
- Step deformities
- Stability
- Crepitation
- ‘Stress test’
- Cranial Nerves V

18. Examination Pearls
Intraoral Exam
Inspection
- Soft tissues and hard tissues (teeth)
- Sublingual hematoma is pathognomic of a mandible fracture
Palpation
- Tenderness
- Step deformities
- Stability
Percussion of teeth
- Pain
- “crack pots” sound

19. Frontal Bone Fractures
Examples

20. Nasoethmoid Fractures
Examples

21. Nasal Fractures
Examples

22. Orbito-Zygomatic Fractures
Examples

23. Maxillary Fractures
Examples – Lefort Classification

24. Mandible Fractures
Examples

25. Mandible Fractures
Examples

26. Conclusion
Referral to Plastic Surgery
Call Early – “We will be able to help with some of the work up and save you time”
- Organize Xrays and CT Scans
- Opthal and other consults
- Keep head elevated + Avoid Nose blowing + Antibiotics