Associated Injuries

Whether the injured patient presents with an isolated maxillofacial injury or with multisystem involvement, the principles of treatment are the same. Establishment of a patent airway should be the most immediate concern. Control of hemorrhage from open wounds or bleeding orifices by pressure dressing or packing should be accomplished next. If shock is present, treatment should include rapid infusion of intravenous lactated Ringer’s solution followed by blood administration as soon as possible. Investigation for possible cranial, thoracic, or intraabdominal injuries should be completed before identifying the maxillofacial abnormalities.

Airway obstruction with subsequent hypoxemia can easily develop in the patient with a maxillofacial fracture. Blood clots, broken teeth or dentures, and foreign bodies, such as dirt or glass, can physically obstruct the airway. The posterior displacement of the tongue secondary to the patient’s position or to a mandibular fracture may occlude the airway. Other potential causes include glossopharyngeal edema and expanding hematoma. In all situations, a patent airway must take immediate priority. Sweeping debris from the oropharynx and mouth by using one’s finger may be a lifesaving technique. Suction, if available, is helpful. Simple traction on a posteriorly displaced tongue by suture or towel clip may alleviate obstruction. If these methods fail, oral intubation must be instituted. If facial edema, facial fractures, or cervical spine fractures prevent oral or nasal intubation, a cricothyroidotomy can be performed through the membrane between the thyroid and cricoid cartilages (Fig. 17-1). This site is a bloodless field, and the procedure can easily be done in the emergency department with only a scalpel. Later, an elective lower tracheotomy can be performed under controlled circumstances in the operating room. A low tracheotomy performed in the emergency department may be very hazardous and should be avoided.

Fig. 17-1 The site for cricothyroidotomy is located between the thyroid and cricoid cartilages.

Hemorrhage from open wounds can be controlled most easily by pressure dressings consisting of layers of gauze (Kerlix) and elastic bandages. Occasionally, an active bleeder in a facial wound may need to be clamped and ligated. However, blind clamping of possible bleeding sites is condemned because of the high incidence of iatrogenic complications, such as facial nerve damage. Nasal hemorrhage may require packing. Shock occurs very seldomly from an isolated maxillofacial injury and most commonly results from a thoracic or abdominal injury.

All patients should be considered candidates for cervical spine fractures, which occur in 4% to 7% of maxillofacial injuries. The initial examination should include palpation of the neck for tenderness over the cervical spine and evaluation of grip strength and motion in all extremities. Before other roentgenograms are taken, a cross-table lateral view of the cervical spine with all seven vertebrae visible should be examined for fracture or dislocation.

The evaluation and treatment of any associated life-threatening injuries that occur in the multiinjured patient must receive first priority. Subdural, epidural, or intracerebral hematoma may be present in a comatose or semilucid patient, indicating the need for skull roentgenograms and computerized axial tomographic scan. Possible chest injuries include rib fractures, pneumothorax or hemothorax, flail chest, aortic rupture, and pulmonary or cardiac contusion. Chest films and arterial gas studies may be indicated. Intraabdominal injuries, of course, would include a ruptured spleen, transected liver, major vessel injuries, and/or perforated intestine. A pregnant woman may suffer an abortion as a result of such an injury. Single or multiple extremity fractures may also be present. After repair and/or stabilization of the associated injuries has been accomplished, reduction of the maxillofacial fractures may be performed.

Examination and Diagnosis

An accurate history should be obtained whenever possible from the patient and/or witnesses at the scene of the accident. The type of accident, the patient’s position in the car, the use of safety belts, the mode of impact, and the patient’s condition at the time of injury are all important considerations in the initial assessment. Because alcohol is involved in 50% of automobile accidents, a blood alcohol sample should be drawn. Ingestion of other drugs should be considered by an appropriate drug screen analysis. A review of the patient’s past history should include other illnesses, previous surgery, allergies, and all current medications.

A diagnosis of facial bone injury can be established by three methods: observation, palpation, and radiologic evaluation. Moderate to severe facial edema may mask bony irregularities and asymmetries (Fig. 17-2). After resolution of the edema, facial asymmetry is suggestive of an underlying fracture. Light manual palpation is important in making the initial diagnosis.

Fig. 17-2 This 32-year-old man suffered a Le Fort III maxillary fracture, nasal fracturesa displaced mandibular fracture, and an undisplaced fracture of the seventh cervical vertebra. The nasal deformity is easily recognized, but the remaining deformities are masked by facial edema.

A systematic approach should be used routinely in examining all potential facial fracture patients. The boundaries of the orbit, the projection of the malar eminences and zygomatic arches, the maxillary and mandibular arches, and the nasal bones should be palpated. During examination, any depressions or step deformities should be noted, as well as any tenderness in areas of potential fracture.

Evaluation of the function of the extraocular muscles may demonstrate superior gaze impairment with subsequent diplopia. Orbital ridge or floor fractures commonly result in infraorbital nerve numbness of the cheek and the maxillary gingiva on the side of the fracture. Crepitus to light touch suggests fracture extension through the nasal airways or paranasal sinuses. Rhinorrhea confirms the involvement of the fracture through the cribriform plate. The presence of trismus may indicate a hematoma or contusion in the muscles of mastication or could suggest either zygomatic arch or mandibular fractures. A complete examination for possible facial injuries includes a thorough evaluation of dental occlusion for any abnormality. The oral cavity should be assessed, and any fractured or missing teeth should be located, if possible, and removed to avoid aspiration.

Radiographic assessment is extremely important in the evaluation of facial fractures. The studies available in most emergency departments should be considered a preliminary evaluation, which will be supplemented by more sophisticated techniques at a later date. Before any radiographs of the facial bones are undertaken, an evaluation of the cervical spine should be completed. Initially, a cross-table portable view of the cervical spine should be obtained to rule out the possibility of neck fracture. If this film is negative, a complete cervical spine series should be done. When this study shows no abnormality, then specific views of the facial bones can be done.

The Waters’ view is the single most informative roentgenogram in evaluation of the maxillofacial patient in the emergency department (Fig. 17-3). This study visualizes the floor and rims of the orbits, the walls of the sinuses, the zygomatic bones, the zygomatic arches, and the nasal septum with minimal interference of other bony structures. Opacity of a maxillary sinus suggests hemorrhage as a result of an orbital ridge and/or floor fracture. The Waters’ view requires the cooperation of the patient and a normal cervical spine, however, because the patient must be in the prone position during the examination. If the patient is comatose, uncooperative, or suspected of having a cervical fracture, a reverse Waters’ view with the patient in the supine position is a satisfactory substitute, because it gives almost the same level of detailed information. Other films worth consideration in the emergency department are the submental vertex view of the zygomatic arches and a mandible series. More sophisticated and detailed studies can be obtained later during the hospitalization or on an outpatient basis for isolated facial fractures.

Fig. 17-3 The Waters’ view is the best single roentgenographic study of the facial bones. It most clearly visualizes the rims of the orbits, the zygomatic bones and arches, and the maxilla. Note the clarity of the maxillary sinuses.

Since the development of computed tomography (CT) scanning, it has become essential for the diagnosis of facial trauma. The CT scan is a more accurate diagnostic study and allows an evaluation of complicated facial fractures before the resolution of edema. Additionally, injuries to the soft tissue structures in the area of trauma can be better evaluated— for example, the optic nerve or orbital herniation of the orbit (Fig. 17-4).

Fig. 17-4 Axial CT of the orbits clearly demonstrates the optic nerve and the medial and lateral rectus extraocular muscles.

The only disadvantage to the use of the CT scan is seen when artifacts caused by either dental fillings or metal appliances occur. Radiation is not considered a disadvantage; CT exposes the patient to a radiation dosage equal to the amount from linear tomography. Studies suggest that the amount of radiation from either study is less than the amount needed to cause cataracts.

The role of magnetic resonance imaging (MRI) in the craniofacial injury patient is primarily confined to evaluation of soft tissue trauma. When injuries to the ocular structures are noted and disturbances of vision are present, MRI may help localize the site of the injury (Fig. 17-5).

Fig. 17-5 MRI of the orbits shows a large hematoma along the roof of the left side, which displaces the globe inferiorly. The eye was blind on initial examination.

Fractures of the Mandible

Although it is the thickest and heaviest of the facial bones, the mandible is the second-most commonly fractured (after nasal bones). Mandibular fractures may occur as isolated injuries or as components of complex maxillary and mandibular fractures. The most common causes of mandibular fractures are acts of violence that may range from simple falls to motor vehicle accidents. Occasionally, systemic diseases such as hyperparathyroidism and osteomalacia may predis pose to mandibular fractures. Infrequently, benign or malignant tumors, cysts, or osteomyelitis may precipitate such fractures.

Factors influencing the severity of the displacement of the fracture segments are multiple and interrelated. The direction and intensity of the force of injury cause different fractures. High-velocity injuries cause a fracture at the site of impact, whereas a slow, less violent force not only causes a fracture at the impact site but also may fracture the opposite condylar neck. A blow to the area of the symphysis may cause fractures of both condylar necks. Second, the site of the fracture may influence the amount of displacement of the segments, depending on the direction of the fracture line and the direction of the different muscle movements in the area. A fracture line that runs downward and forward from the molar area has less displacement than does a line that runs downward and backward. The muscle groups that operate the mandible include the anterior (depressor-retractor) group and the posterior (elevator) group. The anterior muscle group displaces fragments in a downward, posterior, and medial direction, whereas the posterior group displaces fragments in an upward, forward, and medial direction. Consequently, a fracture through the angle of the mandible in a downward and backward direction has a far greater displacement because of the distracting forces of the posterior muscle group. However, if the fracture line is in the downward and forward direction, the muscle pull of the posterior group tends to keep the fracture segments in an anatomic position. Third, the presence or absence of teeth influences displacement of the fractures. Teeth on the proximal segment may decrease the displacement of the fractures by meeting the corresponding teeth of the maxilla. Finally, the presence and extent of soft tissue wounds result in a larger displacement with larger defects.

Clinically, the principal physical abnormality will be varying degrees of malocclusion. The patient may simply state, “My teeth don’t feel right,” or physical examination may demonstrate gross malocclusion. Anesthesia of the lower lip is common in fractures of the body of the mandible. Edema and ecchymosis may mask mandibular asymmetry. On examination, tenderness to palpation over the fracture site and pain with movement are observed. Crepitation may be noted with motion. Oral excursion is decreased. However, the principal physical abnormality is malocclusion.

Although the clinical examination most frequently establishes the diagnosis of mandibular fractures, roentgenographic studies more clearly define the direction of the fracture line, the relationship of the teeth to the fracture, and the degree of displacement. Posteroanterior and oblique lateral views of the mandible demonstrate fractures of the body and the angle without difficulty. If available, a Panorex view of the mandible is an excellent and necessary study that shows fractures at any site. Fractures of the temporomandibular joint and condylar area are sometimes difficult to demonstrate on routine mandibular roentgenograms, however, and may require tomograms for the final diagnosis (Fig. 17-6).

Fig. 17-6 Tomograms of the condylar process are sometimes required to establish a fracture of the condylar neck (arrow).

The most common fracture of the mandible (36%) is in the neck of the condyle. The incidence of fractures in this site is closely followed by that of fractures in the angle of the mandible (20%), the body (21%), and the area of the symphysis (14%). Other sites are much less commonly involved.

The principles of treatment for mandibular fracture include early anatomic reduction of the fracture, immobilization, and control of infection. An isolated mandibular fracture should be reduced at the time of injury. However, if other life-threatening injuries are present, treatment of the mandibular injury may be postponed for 7 to 10 days. All mandibular fractures are considered compound if the slightest displacement is present, and consequently, preoperative and postoperative antibiotics are recommended. Immobilization requires at least the application of arch bars and intermaxillary fixation (IMF) with rubber bands or wires for a minimum of 5 weeks. Rigid fixation with plates or screws is an option. Because IMF is not usually required after rigid stabilization, patients are able to begin a soft diet almost immediately after open reduction. Consequently, the weight loss and compromised oral hygiene present in patients with IMF are markedly reduced. The use of compression plates has also made the treatment of edentulous patients with mandible fractures much simpler.

Early complications of mandibular fracture may include infection, avascular necrosis, osteitis, and osteomyelitis. Predisposing factors to infection are poor oral hygiene, multiple caries, or a compound fracture. Diabetic patients are more susceptible to infections. Acute infection manifests as an abscess and is reflected by pain, swelling, and erythema in the area of the abscess. Incision, drainage, and systemic antibiotics constitute the treatment of choice. Chronic infections such as osteitis and osteomyelitis usually occur when a comminuted fracture with an avascular bone segment has occurred. Pain and roentgenographic changes suggestive of osteomyelitis are usually evident. Late complications may also include malocclusion or nonunion, and these require further corrective surgery.

Fractures of the Maxilla

Fractures of the maxilla, or midface, most commonly are caused by a high-velocity–type injury. Their incidence in recent years has decreased, primarily because of lower highway speed limits and increased use of seat belts. However, such injuries may occur in collisions at speeds as low as 30 miles per hour. The force necessary to cause fractures of the maxilla also increases the likelihood of severe injuries to other organ systems. Associated injuries of various degrees of severity more frequently involve the head but also occur in the chest and abdomen. Skeletal injuries may be present in approximately one third of the patients, whereas blindness is observed in one tenth. Additionally, the frequency of cervical spine injury is much higher with this injury than with other types of facial fractures.

Maxillary fractures can be divided into two groups: vertical and horizontal. Vertical fractures split the palate on either side of the septum. However, the three classic fractures of the maxilla are those horizontal defects described by Le Fort (Fig. 17-7). The Le Fort I (transverse) fracture is a horizontal fracture immediately above the level of the teeth. The Le Fort II fracture has the configuration of a pyramid, with the apex being across the nasal bridge. It extends through the nasal bones, the frontal processes of the maxilla, the lacrimal bones, the inferior rim and floor of both orbits, and the maxillozygomatic suture line. From this last point, the fracture continues posteriorly through the lateral wall of the maxilla and the pterygoid plates into the pterygoid maxillary fossa. The Le Fort III fracture separates the craniofacial complex and extends through the zygomaticofrontal, maxillofrontal, and nasofrontal suture lines, the floors of the orbit, and the ethmoid and sphenoid bones (Fig. 17-8).

Fig. 17-7 Le Fort fracture lines.

Fig. 17-8 A Le Fort III craniofacial separation (arrows) is evident in a Waters’ view of an 8-year-old patient. The opacity of the left maxillary sinus is more severe than the right.

Clinically, the patient may be comatose and may require immediate neurosurgical consultation. If conscious, there may be complaints of the inability to “match” the teeth properly. Infraorbital nerve numbness may be present. In Le Fort II or III fractures, nasal hemorrhage is usually evident. On physical examination, facial deformities may be masked by edema and ecchymosis. Bimanual palpation along the orbital ridges may detect steplike deformities or separations and tenderness. Forward movement of the maxilla is elicited with all three types of Le Fort fractures; in the Le Fort III fracture, the entire midthird of the face may move. However, occasionally these fractures may be impacted, and no movement will be evident. Malocclusion can be an initial sign and should suggest a maxillary fracture if the mandible is intact. Extraocular muscle dysfunction may be manifested by diplopia with superior gaze. Blindness is uncommon but may occur.

With extension of the maxillary fractures into the cribriform plate, rhinorrhea mixed with blood is detected as a result of the dural defect. The patient may note a salty taste in the back of the mouth. Any clear fluid from the nose should be tested for glucose. Glucose levels greater than 30 mg/100 mL confirm the presence of cerebrospinal fluid (CSF) and a tear in the dura. In this case, the patient’s nose should not be packed, despite the possible presence of depressed nasal fractures, and the patient should be instructed not to blow his or her nose. Prophylactic antibiotics that cross the blood–brain barrier should be instituted to decrease the possibility of the development of a retrograde infection. When meningitis has occurred in this type of injury, the most common organism isolated has been Pneumococcus, sensitive to penicillin.

Roentgenographically, the Waters’ view is the most reliable in demonstrating maxillary fractures in the emergency department. For vertical or alveolar fractures, occlusal views are more suitable. CT scans of the facial bones more accurately detail the full extent of the fractures. The study is usually done in the coronal view and shows the amount of the comminution, the degree of rotation, and the extent of displacement of the fracture segments (Figs. 17-9 and 17-10). Additionally, injury to the optic nerve or fat herniation may be visible.

Fig. 17-9 Coronal CT scan of multiple facial fractures shows obvious injuries to the nasoethmoid complex, horizontal maxilla (Le Fort I) and orbital rims.

Fig. 17-10 A more posterior CT scan view of the fractures in Fig. 17-9 reveals extensive orbital floor fractures.

When rhinorrhea has persisted for more than 2 to 3 weeks after the injury or after reduction of the facial bone fractures, an intrathecal injection of metrizamide contrast by lumbar puncture before CT scanning localizes the cranial defect for the neurosurgeon.

Initially, the airway may be compromised by the posterior displacement of the maxillary fractures or by the combination with mandibular fractures. An endotracheal tube is the preferred treatment, although a cricothyroidotomy occasionally may be necessary.

Over the past 10 years, the management of maxillofacial fractures has undergone a complete evolution. No longer is surgical repair delayed until facial edema has resolved. Currently, wide exposure of all fracture segments, precise anatomic reduction with rigid internal fixation, and intermediate bone grafting are the standards for appropriate treatment for maxillofacial injuries. Exposure of the entire facial skeleton can be obtained through four incisions that are aesthetically acceptable.

Rarely is a tracheotomy required in the isolated midface fracture. Maxillary fractures combined with pulmonary or thoracic injuries may require a tracheotomy to ensure proper ventilation and adequate pulmonary toilet postoperatively.

In the edentulous patient with minimal displacement of the midface, correction of the anatomic defect may be maintained by adjustment with new dentures. Any significant displacement requires open reduction and internal fixation with rigid stabilization.

Occasionally, the patient with extensive maxillary fractures also suffers a severe head injury with resultant coma. After stabilization of the neurologic status and with the approval of the neurosurgeon, correction of the maxillary fractures is recommended. If treated within 3 weeks of injury, adequate reduction and fixation of the fracture can be accomplished. Otherwise, months may elapse before some degree of consciousness occurs, and surgical intervention then will be markedly more difficult, will probably require osteotomies with bone grafting, and will have less satisfying results.

Usually, rhinorrhea spontaneously ceases about 5 days after injury. Alternatively, the CSF leak ceases with adequate reduction of the maxillary fractures. If rhinorrhea continues 3 weeks after injury or after reduction, a craniotomy is required to close the dural defect.

The use of compression plates allows the airway to be easily managed and lessens the patient’s stay in the intensive care unit. Postoperatively, improved oral hygiene and food intake result in the patient’s quicker rehabilitation. And finally, the use of plates avoids the possible midfacial shortening and/or midfacial retrusion sometimes seen with wire fixation and craniomandibular suspension.

Late complications of maxillary fractures include nasal obstruction, chronic sinusitis, and lacrimal duct dysfunction. Anesthesia or hypoesthesia of the infraorbital nerve may persist. Malunion of the fracture may occur and requires planned osteotomies with bone grafting for correction. Malocclusion after treatment may occur about 20% of the time. Orthodontics usually can correct this problem; only in severe cases are reconstructive osteotomies required.

Fractures of the Zygoma

The zygoma, or malar bone, forms the prominence of the cheek and, consequently, is frequently injured. The usual cause of a zygoma fracture is the low-intensity, less violent type of injury: fistfights and falls.

The zygoma articulates with the maxillary, frontal, and temporal bones. Injury to it may cause a separation at the suture lines in an isolated injury or may be combined with fractures of the middle third of the face. If displaced, the zygoma is depressed in the direction of the traumatic force, which most commonly is in the posterior, downward, and medial direction. Although six different groups of malar fractures have been described, fractures of the zygoma are basically either an isolated zygomatic arch fracture (Fig. 17-11) or the “tripod” fracture (Fig. 17-12).

Fig. 17-11 A markedly depressed left zygomatic arch fracture is demonstrated by a submental-vertex view.

Fig. 17-12 A comminuted left tripod malar fracture is visualized on a Waters’ view. A step deformity of the orbital rim can be anticipated on physical examination (arrows). Note the opacity of the left maxillary sinus.

Clinically, the patient may complain of pain in the area of the zygomatic arch when attempting to open the mouth. Infraorbital nerve anesthesia may be present in both the ipsilateral cheek and the maxillary gingiva (gingival numbness suggests orbital floor and rim fractures). Diplopia with upward gaze may also be noted.

On initial examination, the anatomic abnormalities may be masked by significant edema. Ecchymosis may involve the conjunctiva and sclera as well as the eyelids. Bimanual palpation of both the orbital rims and the zygomatic arches should be done simultaneously and may elicit tenderness at the fracture site.

Ocular injury occurs in 25% of facial bone fractures, and complete blindness develops in 14% of these cases. The incidence of ocular injury is greatest when the fractures involve the bones of the orbit. Consequently, patients with fractures of the zygoma, orbit, or frontal bone are at greater risk for such injuries.

It is essential that ocular assessment be done at the initial evaluation of the facial bone fracture patient. Often, edema may develop rather quickly, which would prevent a complete ocular examination at a later date.

The initial ocular assessment should involve five parameters: (1) visual acuity, (2) pupillary reactions to light, (3) eyelid or globe lacerations, (4) funduscopic examination, and (5) ocular motility. The visual acuity can be grossly evaluated by assessing the patient’s ability to read material, count fingers, or merely perceive light. The pupillary reactions to light should be assessed by direct stimulation of the pupil in comparison to an alternating light testing procedure. Direct stimulation of the pupil should elicit a constrictive reaction. The alternating light testing procedure requires moving a light from the normal eye to the injured eye. Initially a dilatation occurs before the constriction. The eyelids and globe should be evaluated for any lacerations. Funduscopic examination should check for both the red reflex and for visualization of the retina. Ocular movement should be evaluated by having the patient’s eyes follow the examiner’s finger throughout the full range of motion. If there are any concerns after the initial evaluation is completed, an immediate ophthalmology consultation should be obtained.

After resolution of the edema, depression over the zygomatic arch, step-off deformities of the orbital rim, flattening of the malar eminence, or inferior displacement of the lateral canthus may be more apparent. Oral excursion may be limited to less than 2 cm. (Limitation of oral excursion can occur if the zygomatic arch is depressed 1 cm and impedes the movement of the coronoid process of the mandible.) Diplopia with superior gaze may be present if the inferior rectus muscle is trapped by an orbital floor fracture. Enophthalmos may occur if a significant orbital floor defect is present.

The best roentgenographic studies obtainable from the emergency department are the Waters’ view of the facial bones and the submental-vertex view of the zygomatic arches. Displacement of the malar fragment and/or opacity in the maxillary sinus is readily visible on a Waters’ view. A CT scan of the orbits must be obtained to further delineate the extent of the fractures (Fig. 17-13).

Fig. 17-13 A coronal CT scan demonstrates a displaced left malar fracture. Opacification of the left maxillary sinus is clearly evident. Also note the ability for the CT scan to demonstrate the extraocular muscles.

Surgical reduction of the isolated zygomatic arch fracture can be done either intraorally or extraorally on an outpatient basis. After reduction of the bony fragments, stabilization is secured by placement of plates across the fracture lines at two or three sites. Fractures of the zygoma should be reduced within 3 weeks of injury.

Postoperatively, antibiotic coverage is continued for one week. A light dressing may be applied over the ipsilateral eye, but it is removed on the first postoperative day. The patient’s muscular symmetry and extraocular muscle function are monitored weekly.

Complications secondary to zygoma fractures are unusual but include infection, malunion, and nonunion. Infection usually occurs in those cases requiring orbital floor reconstruction with an implant, especially if the maxillary sinus has also been packed. The infection may develop early or late with respect to the repair of the fracture and requires removal of the implant, as well as antibiotics administered for systemic effect. Malunion of the zygoma may cause facial asymmetry and interference with mandibular function. Correction can be achieved by osteotomies at the zygomaticofrontal and zygomaticomaxillary suture line, elevation of the zygoma, bone grafting, and fixation. Nonunions necessitate bone grafting and rigid fixation. Any residual contour deformity may be corrected at a later date with the use of onlay bone, cartilage, or synthetic grafts.

Blow-Out Fractures

Strictly speaking, the term blow-out fracture should be restricted to fractures of the orbital floor without involvement of the orbital rim. Blow-out fractures result from the transmission of a sudden increased intraocular pressure through the weakest point of the orbital floor, most commonly near the infraorbital nerve canal. A second common site of fracture is the medial orbital wall.

The most common cause of blow-out fractures is the automobile accident. One third of the cases usually result from blunt injury secondary to fist blows, ball injuries, falls, and other forms of trauma. Although the orbital rim protects the eyeball itself against direct injury from objects larger than 5 cm, ocular injury must be ruled out in all blow-out fractures. The incidence of ocular injury with orbital fractures varies widely, but the incidences of hyphema and retinal hemorrhage appear to be the most common. However, more severe injuries such as decreased vision or blindness may also occur. Direct ocular injury is more common in low-velocity injuries than in automobile accidents.

During examination, the patient may volunteer the presence of diplopia, infraorbital nerve numbness, and possibly, decreased vision. Clinically, periorbital edema and ecchymosis may handicap the initial examination. but the eyelids can usually be pried open to allow a gross examination of vision and light perception. Diplopia may occur as a result of limitation of superior gaze (Fig. 17-14). As the periorbital edema resolves, diplopia may lessen in severity. If the periorbital edema is minimal, enophthalmos may be present.

Fig. 17-14 Impairment of superior gaze occurred after a blow to the left eye. A traction test confirmed entrapment of the inferior rectus muscle.

The most common causes of diplopia in blow-out fractures are entrapment of the inferior rectus muscle, inferior oblique muscle, or periorbital fat herniation. Other causes of immediate diplopia include injury to cranial nerves III, IV, and VI; direct injury or hemorrhage into the extraocular muscles; or displacement of the eyeball into the maxillary sinus. The “traction test” simplifies the differential diagnosis. Topical anesthesia is applied to the conjunctiva. The eyeball is pinched with a fine forceps at the insertion of the inferior rectus muscle and rotated. If rotation of the eyeball cannot be accomplished, entrapment of the inferior rectus muscle is demonstrated. If rotation of the eyeball is achieved, then the diplopia can be traced to one of the other causes.

Enophthalmos may be evident on the initial examination or masked by the periorbital edema. With subsequent resolution of the edema, enophthalmos becomes more apparent. The mechanisms of enophthalmos include herniation of the orbital fat into the maxillary sinus, posterior position of the ocular globe due to entrapment of the inferior rectus muscle, or the downward displacement of the ocular globe through a large orbital floor fracture. Additionally, enophthalmos may develop as a result of orbital fat necrosis secondary to the injury, to pressure from an orbital hematoma, or to a low-grade inflammatory process.

The most pertinent roentgenographic studies are a Waters’ view initially, followed by a CT scan. A coronal CT scan is the most accurate in diagnosing this defect. However, its use may be limited by the positioning requirements of the patient or by the presence of multiple dental fillings. Abnormal findings include lowering of the orbital floor, orbital fat entrapment in the maxillary sinus (Fig. 17-15), or massive orbital contents displacement into the maxillary sinus.

Fig. 17-15 A coronal CT scan demonstrating a left blow-out fracture. Soft tissue entrapment can be seen. Note the artifacts created by the dental fillings on the right side.

Treatment of blow-out fracture is twofold. If definite ocular injury is demonstrated on initial examination, an ophthalmologic consultation must be obtained immediately. If no ocular injury is present, surgical considerations are postponed until the resolution of periorbital edema. The two primary indications for surgical correction of a blow-out fracture include diplopia confirmed by a positive traction test or enophthalmos. Usually, roentgenographic evidence supports the diagnosis of a blow-out fracture, but a normal study should not postpone surgery if there is a positive traction test or enophthalmos present.

The surgical procedure should be performed within 2 weeks after injury, because the incarcerated contents become more difficult to release after this period. If surgery is postponed more than 2 or 3 weeks, motility problems and enophthalmos may appear as late complications. The surgical procedure consists of exploration of the orbital floor through a lower eyelid incision, release of the entrapped inferior rectus muscle, retrieval of the herniated orbital contents, and reconstruction of the orbital floor with either a synthetic implant or a cranial bone graft.

Antibiotics are recommended both preoperatively and postoperatively because of the involvement with the maxillary sinus. An eyepatch is usually applied at the completion of the operation and removed on the first postoperative day. The patient is followed as an outpatient for persistence of either diplopia or enophthalmos.

Useful binocular vision at the end of 3 months commonly occurs. However, if diplopia is not improved by that time, an ophthalmology consultation is required for further evaluation and possible prescription of glass prisms to allow useful vision. After 6 months, extraocular muscle surgery may be necessary to correct the persistent diplopia.

The persistence of enophthalmos presents a very difficult problem. Enophthalmos may be corrected by osteotomies and reconstruction with a cranial bone graft. However, this surgical procedure is a major effort to correct a deformity that might have been prevented at the initial surgical repair.

Nasal Fractures

The pair of nasal bones present at the top of the nose comprise about one third of its length (Fig. 17-16). Each bone attaches to a distal nasal cartilage. The two nasal passages are separated by a cartilaginous septum, the base of which is attached to the nasal crest of the maxilla. The septum also attaches to the ethmoid and vomer.

Fig. 17-16 Anterior (A) and lateral (B) views of the nasal bones, septum, and supporting structures. (C)Lateral radiograph showing fracture of the nasal bone.

Fractures of the nasal bones are the most common of all facial bone fractures. Early treatment allows easy reduction with satisfactory cosmetic and functional results. Neglect of treatment may produce both a physiologic and a cosmetic deformity much more difficult to correct.

The types of nasal fracture may vary from a simple displacement of the nasal pyramid from a lateral blow to a more complex comminuted fracture with a resultant “smashed”-nose appearance from a frontal force. Associated injuries include fractures extending through the cribriform plate, medial canthal ligament displacement, or lacrimal gland or duct injuries. (Because the medial canthal ligament of the eye attaches to the base of the nose, injury at this site may damage the ligament, allowing the globe to move laterally, a condition known as telecanthus.) Other sequelae of the comminuted nasal fracture include traumatic dacryocystitis and epiphora.

Most nasal fractures are diagnosed by clinical evaluation, and radiographs are usually not needed. The presence of preexisting disease, nasal deformity, or a previous nasal operation should be investigated at the time of the initial examination. On physical examination, nasal and periorbital edema are common. Nasal obstruction may be present secondary to edema, clots, or displaced nasal bone fractures. Movement of the nasal bone fragments may be elicited by palpation. Subcutaneous emphysema may be present. The possibility of a telescoping-type injury should be considered if the nasolabial angle is greater than 100 degrees (especially in males) or if a step deformity is noted dorsally at the junction of the nasal bone with the septum.

The importance of identifying a hematoma of the septum at the time of the initial examination cannot be stressed too strongly. If overlooked, a septal hematoma (blood that accumulates beneath the septal perichondrium) can progress either to a partial nasal obstruction or to a septal perforation. Topical application of 10% cocaine shrinks the nasal mucosa and allows examination of the nasal passageways by a speculum. Palpation can also help differentiate hematoma from a deviated septum. The presence of a septal hematoma should be treated immediately by incision and drainage. Failure to drain the hematoma can also lead to infection or pressure necrosis of bone and cartilage. The septum may then collapse, leading to the poor cosmetic appearance known as saddle nose.

Very often, the posteroanterior and lateral roentgenographic views of the nasal bones are not very helpful in supporting the clinical impression of a nasal fracture. A Waters’ view may better demonstrate fractures of either the nasal septum or the bony pyramid. However, the clinical impression is much more meaningful in diagnosing this fracture.

Ideally, nasal fractures should be treated within a few hours of original diagnosis. Proper reduction can be assessed visually and by palpation. Usually, however, the presence of nasal edema does not permit immediate reduction. A period of 3 to 5 days is then needed before accurate operative assessment is possible. By then, the edema will have resolved sufficiently to allow satisfactory inspection. Most simple fractures are treated by closed reduction. However, complicated fractures that result from a frontal impact are more likely to be treated by an open reduction. The fragments are reduced under direct vision and wired together. Medial canthal ligament injuries are repaired. Bone grafting may be done.

Although closed reduction can be performed with the patient under either general anesthesia or a combination of local and topical anesthesia, general anesthesia is recommended to protect the airway from posterior nasal bleeding. After reduction, a nasal speculum should be used to demonstrate the patency of the airways and to evaluate the position of the nasal septum. A displaced septum should be returned to its position in the vomerine groove. Nasal packing is inserted to maintain the nasal bone reduction, and a splint is applied for further stabilization.

Postoperatively, the nasal packing is left in place for approximately 5 days and the nasal splint for 7. During the second week, the nasal splint is usually worn only at night. Any activity that would endanger the nasal reduction (for example, contact sports) should be avoided for 6 weeks. During the interval of packing, nasal decongestants and antibiotics are used.

Late complications of nasal fracture include nasal deformity or airway obstruction. The nasal deformity may be secondary to malunion of the nasal bones or to a septal injury. Malunion usually occurs as a result of the patient’s failure to seek early medical attention. Correcting a nasal fracture after 14 days past the injury is rarely successful and requires rhinoplasty to correct the deformity. Persistent nasal deformity or airway obstruction may be caused by a septal injury and also requires rhinoplasty and possible submucous cartilage resection for correction. In the pediatric age group, rhinoplasties are normally postponed until the age of 15 years to avoid any possible growth disturbances with the development of the nose. In the adult, rhinoplasty can be performed after satisfactory wound healing has occurred, usually about 3 months after the injury.

NOTE: Epistaxis often occurs with nasal injuries. Most often, the bleeding originates from the anterior septum. Anterior epistaxis may be controlled by slightly reclining the patient and applying pressure to the septum for 5 to 19 minutes. Ice to the neck may help by causing reflex vasoconstriction. Persistent bleeding may require packing.

Frontal Sinus Fractures

Frontal sinus fractures are not common, but warrant special considerations. Such injuries are usually accompanied by fractures of other facial bones and may be associated with an intracranial injury. On clinical examination, anesthesia of the forehead and scalp may be present as a result of soft tissue injury to the supratrochlear and supraorbital nerves. If a depressed supraorbital ridge fracture is present, diplopia is demonstrated as a result of dysfunction of the superior rectus and superior oblique muscles. Periorbital ecchymosis and edema are present, which may mask the frontal depression secondary to the fracture. Tenderness and crepitation to palpation may be elicited. Rhinorrhea may also be noted.

Roentgenographic studies should include a skull series and Caldwell and lateral views of the facial bones. If air fluid levels or cloudiness is seen in the sinus or if a pneumocephalus is present, a CT scan in both axial and coronal views should be obtained. The presence of an intracranial aerocele is pathognomonic for a dural tear and would implicate a fracture of the posterior wall of the frontal sinus.

The treatment of frontal sinus fractures depends on the extent of the fracture, the amount of fragmentation present, nasal frontal duct involvement, and the presence of a dural tear with CSF leak. Antibiotic coverage should begin on the day of injury. Surgical correction of a depressed or compound anterior wall fracture requires elevation and wiring or microplating of the bony fragments. Treatment of posterior wall fractures is controversial and involves open exploration with sinus obliteration by any variety of ways. In the presence of a dural tear, a transfrontal craniotomy with repair of the dura should be done in conjunction with reduction of the fracture or cranialization of the sinus.

Potential complications of frontal sinus fractures can be life threatening. A posterior wall fracture with a dural tear may develop either a retrograde meningitis or brain abscess. Frontal sinus infections may also extend into the orbital cavities. The frontal sinus duct may be obstructed with the subsequent development of a mucocele.

Facial Fractures in the Pediatric Patient

The incidence of facial fractures in the pediatric age group varies widely, partly because plain radiographs are unreliable in the diagnosis of such injuries in children. There are few large series of pediatric facial fractures reported in the literature. Consequently, controversies regarding the incidence, the effect of injury on growth, and the actual treatment of such injuries have not been resolved.

The facial skeleton is constantly changing from birth to the age of 18. Facial bones initially are resilient, but brittleness begins to increase significantly after the age of 2 to 3. The paranasal sinus development changes the vulnerability of the facial bones to injury. The maxillary sinus aeration begins at birth and continues until the age of 12. The frontal sinus aeration begins approximately at 5 years of age and continues to late puberty. The role of dentition and the mixed dentition present in pediatric patients limits the ability to adequately stabilize either the maxillary or mandibular fractures.

Certain apparent patterns of facial bone fracture can be generalized, however. Skull fractures are more common than facial bone fractures in the pediatric age group younger than 12 years. Mid-facial fractures are extremely rare before the eighth birthday. Mandibular fractures that occur in the pediatric population younger than 10 years involve the condyle 66% of the time. After the age of 15, the adult pattern of mandibular fracture prevails. Forty percent of all patients with facial bone fractures have skull fractures. In the earlier pediatric age group, most fractures probably are greenstick because of the resiliency of the facial bones.

The diagnosis of facial bone fractures in the pediatric patient is difficult both clinically and radiographically. The child may not understand or be able to answer questions about the injury. Cooperation in the physical examination may also be difficult to obtain, but tenderness to palpation usually can be elicited. The key factor in identifying faciasl bone fractures in the pediatric age group is maintaining a high level of suspicion. Because plain radiographs are notoriously unreliable in the diagnosis, axial and coronal CT scans must be obtained in children when facial fractures are suspect.

In general, the treatment plan for facial fractures of pediatric patients may not be guided by the principles of adult treatment described earlier. Three types of injuries may be present. First, the minimally displaced fracture in the pediatric age group may do best if left alone and simply observed. Second, severely displaced fractures require anatomic reduction and stabilization, especially in the older child. Third, fractures between the first two groups in patients with a high degree of facial growth potential may not require aggressive surgical treatment.

In general, the principles of wide exposure and rigid fixation are not always applied to the pediatric patient. (This is similar to fractures of the extremities in children, in which open surgical intervention is rarely performed.) Although wide exposure to the craniofacial abnormalities of the upper third of the face and skull are well tolerated, some have questioned whether scarred soft tissue of the mid-face may inhibit growth or lead to secondary growth disturbances.

Eventually, facial deformity may become apparent as a result of abnormal development secondary to growth center injury from a facial bone fracture. Therefore, the importance of making an early diagnosis cannot be overemphasized. Even if the facial fractures are minimally displaced and require no surgical treatment, the long-term effect on growth must be monitored. Some patients have compensatory overgrowth on the injured side, whereas others may have less growth. The parents of the patient should be alerted to the possibility of growth abnormality, and the child should be observed throughout adolescence. Any abnormality that may develop would then require further evaluation and possible surgical intervention.

Soft Tissue Injury Management

Soft tissue injuries are commonly seen on a daily basis in any emergency department or general medical office. The appropriate management includes not only the examination of the wound itself but also evaluation for any deeper injury and repair by the appropriate methods. Complicated wounds require the expertise of a surgical specialist. However, many wounds are simple and can be treated either in the emergency department or by the primary care physician.

The general principles of wound repair apply to injuries occurring in any region of the body. A thorough examination should be performed before any local anesthesia is administered. If the injury involves the face, evaluation of facial nerve function can be done by simply asking the patient to raise the eyebrows, close the eyes, and smile. If any weakness is present, then a nerve injury should be considered. Vertically oriented lacerations across the cheek have a potential underlying parotid duct injury, especially if the laceration appears to extend into the parotid gland. Cannulating Stensen’s duct opposite the second maxillary molar can often be done in the emergency department. Injection of methylene blue solution allows the diagnosis to be made. If either a parotid duct or facial nerve injury is identified, the patient should be referred to a surgical specialist for management in the operating room.

Most soft tissue injuries are isolated and can safely be managed in the emergency department or office. Such wounds may range in severity from simple alacerations to dog bite injuries to more complicated soft tissue wounds. For those lacerations that do not require the expertise of a surgical specialist, simple general principles may guide the emergency department or primary care physician in a prompt and satisfactory repair.