Facial TraumaJoni Skipper, MS-IVUSC School of MedicineDiagnosis? lThis child presented with diplopia following blunt trauma to the right eye. On exam, he was unable to move his right eyeball up on upward gaze.Blowout Fracture of the OrbitlFractures of the orbital floor may occur with orbital wall fractures or as an isolated injury. The isolated injury is usually caused by application of pressure to the globe of the eye by objects with a radius of curvature of 5 cm or less. When the orbital floor, being the weakest area, gives way, herniation of orbital contents down into the maxillary sinus may occur (hanging drop sign).lPatients may present with enophthalmos, impaired ocular motility, diplopia due to entrapment of the inferior rectus muscle within the fracture fragments, and infraorbital hypoesthesia. CT: Blowout Fracture of OrbitlA: Orbital blowout fracture with displacement of the floor (arrow), distortion of the inferior rectus, and herniation of orbital fat through defect. Arrowhead indicates medial fracture.lB: Note opacified left anterior ethmoid air cells and displaced medial orbital fracture (arrowheads).Approach to the Patient with Traumatic Injury of the FaceFacial trauma is defined as injury to the soft tissues of the face (including the ears) and to the facial bony structures.May result in hemorrhage and airway obstruction accompanied by multisystem involvement (as many as 60% of patients have associated injuries)Evaluation includes history, physical exam, and diagnostic imaging History of Traumatic EventlWhat was the mechanism of injury?lWas the patient mobile, restrained, or stationary?lIs the injury the result of blunt or penetrating trauma?lWas the object that caused the injury mobile or stationary?lCan the degree of energy transfer be estimated?lAre there any associated thermal or chemical injuries present?Additional HistorylWhere is the location of any facial pain or numbness?lAre there vision problems, such as diplopia, present?lDoes movement of the mandible produce pain?lIs there an abnormal “bite present?The External Bony Facial SkeletonlComposed mainly of the frontal bone, temporal bones, nasal bone, zygomas, maxilla, and mandible.lEthmoid, lacrimal, sphenoid bones contribute to inner portion of orbitslUpper third - above superior orbital rimlMiddle third (midface)- superior orbital rim down through maxillary teethlLower third - mandible Bones of the Facial SkeletonPhysical ExaminationlFirst, inspect face for deformity and asymmetrylEnophthalmos, proptosis, ocular integrity, ocular movementslNasal septum for position, integrity, and presence of septal hematomalEpistaxis or CSF rhinorrhea Physical ExaminationlComplete neurological exam must be performed on any patient with suspected facial traumalSensation - test all 3 major branches of the trigeminal nervelMotor function - assess facial nerve by having patient wrinkle forehead, smile, bare teeth, and close eyes tightlyPhysical ExaminationlPalpation of facial structures - the infraorbital and supraorbital ridges, zygoma, nasal bones, lower maxilla, and mandiblel Assess for tenderness, bony deformities, crepitus, and false motionlMalocclusion or step-off in dentition may be sign of mandibular fractureDiagnostic ImaginglShould focus on bony integrity, fluid-filled sinuses, herniation of orbital contents, and subcutaneous airlOverall status of the patient, physical exam findings, and the clinicians initial impression determine timing and nature of imaging orderedPlain filmslTraditionally the mainstay in the radiographic evaluation of facial traumalStandard plain film facial series: Waters (occipitomental), Caldwell (occipitofrontal), and lateral viewslPanoramic films are used to best evaluate mandibular fracturesCT lOffers a viable, cost-effective alternative to plain filmslVery helpful in the evaluation of facial trauma when facial edema, lacerations, other injuries, or altered level of consciousness limit usefulness of clinical examlConsider institutional wait and turnaround timeMRlLimited role of MR in evaluation of facial trauma due to insensitivity of MR to fractureslUsed to provide complimentary information to CT in the evaluation of the eye and its associated structuresForce of Gravity Impact Required for Facial Fracture BoneForce of gravity (g)Nasal bones30Zygoma50Angle of mandible70Frontal-glabellar region80Midline maxilla100Midline mandible (symphysis)100Supraorbital rim200Nasal FractureslMost common site of facial trauma due to locationlMay be displaced laterally or posteriorlylRequires control of epistaxis and drainage of septal hematoma, if presentZygomatic FractureslTripod fracture: zygomaticofrontal suture, zygomaticotemporal suture, and infraorbital foramenlPresent with flatness of the cheek, anesthesia in the distribution of the infraorbital nerve, diplopia, or palpable step defectMaxillary FractureslLe Fort I maxillalLe Fort II maxilla, nasal bones, and medial aspects of orbits (pyramidal disjunction)lLe Fort III maxilla, zygoma, nasal bones, ethmoids, vomer, and all lesser bones of the cranial base (craniofacial disjunction)lUsually in combinationMandibular FractureslAny patient with malocclusion after facial trauma is assumed to have mandibular fracture until proven otherwisePanoramic X-Ray Film of the MandiblelNote fractures in left angle and right body of mandiblelMultiple fractures are present more than 50% of the time and are usually on contralateral sides of the symphysis