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The identification of facial injury and the restoration of normal
appearance, sight, mastication, smell, and sensation are all essential
tasks,1 but focus first on protecting the patient’s
airway during the primary survey and the other initial considerations
described in Table 256-1.
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Up to 44% of patients with severe maxillofacial trauma
require endotracheal intubation due to mechanical disruption or
massive hemorrhage into the airway.2 The incidence
of associated injury to the brain, orbit, cervical spine, and lungs
is directly related to the mechanism of
injury and severity of facial fractures.2,3 The
evaluation of facial injuries should occur as part of the secondary
survey only after managing life-threatening injuries. Because up
to 6% of patients with maxillofacial trauma will develop
vision loss, a detailed eye examination is essential, especially
in patients with high energy mechanisms, orbital fractures, significant
head injury, and abnormal pupillary findings.4
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Assaults, motor vehicle crashes, falls, sports, and gunshot wounds
account for the majority of facial fractures (in descending order
of incidence), with motor vehicle crashes and gunshot wounds resulting
in a higher severity of injury.5 The lack of a
seat belt or airbag increases the risk of facial fractures and panfacial
fracture.6 The most common fractures are to the
nasal bone, followed by orbital floor, zygomaticomaxillary, maxillary
sinuses, and mandibular ramus.5 Mechanisms and
injury patterns vary with geography. In the urban setting, penetrating
trauma and assaults result in midface and zygomatic fractures. In
the rural setting, motor vehicle crashes and recreational injuries
result in fractures of the mandible and nose. Domestic violence
and elder and child abuse must always be considered in any patient
presenting with facial trauma. The majority of abused women and
children will have injuries to the head, face, and neck.7,8
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The facial skeleton is designed to create effective mastication.
Vertical and horizontal buttresses are formed by bony arches joined
at suture lines. Stronger vertical buttresses are formed by the
zygomaticomaxillary buttress laterally and the frontal process of
the maxilla medially. Weaker horizontal buttresses are formed by
the superior orbital rims, orbital floor, and hard palate. The orbit
itself is comprised of seven different bones, with the inferior
and medial walls being particularly fragile. Therefore, frontal,
lateral, and oblique forces often result in facial fractures.
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The mechanism of injury helps estimate the extent of injury.
Exact details ...