Chapter 259: Trauma to the Face

INTRODUCTION AND EPIDEMIOLOGY

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.¹ The lack of a seat belt or air bag increases the risk of facial fractures and panfacial fracture.² The most common fractures are to the nasal bone, followed by orbital floor, zygomaticomaxillary, maxillary sinuses, and mandibular ramus.¹ 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. Males are more frequently affected than females, but 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.^3,4

PATHOPHYSIOLOGY

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.

The identification of facial injury and the restoration of normal appearance, sight, mastication, smell, and sensation are all essential tasks,⁵ but the principal focus should be on protecting the patient’s airway during the primary survey and the other initial considerations described in Table 259-1.

Up to 44% of patients with severe maxillofacial trauma require endotracheal intubation due to mechanical disruption or massive hemorrhage into the airway.⁶ 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.^6-8 Evaluate facial injuries 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 ...