Facial Trauma

Joni Skipper, MS-IV

USC School of Medicine
Diagnosis?
This 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 Orbit
Fractures 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).
Patients 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 Orbit
A: 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.
B: Note opacified left anterior ethmoid air cells and displaced medial
orbital fracture (arrowheads).
Approach to the Patient with
Traumatic Injury of the Face
Facial 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 Event
What was the
mechanism of injury?
Was the patient
mobile, restrained, or
stationary?
Is the injury the result
of blunt or penetrating
trauma?

Was the object that
caused the injury
mobile or stationary?
Can the degree of
energy transfer be
estimated?
Are there any
associated thermal or
chemical injuries
present?

Additional History
Where is the location
of any facial pain or
numbness?
Are there vision
problems, such as
diplopia, present?


Does movement of the
mandible produce
pain?
Is there an abnormal
bite present?

The External Bony Facial
Skeleton
Composed mainly of the frontal bone, temporal
bones, nasal bone, zygomas, maxilla, and
mandible.
Ethmoid, lacrimal, sphenoid bones contribute to
inner portion of orbits
Upper third - above superior orbital rim
Middle third (midface)- superior orbital rim down
through maxillary teeth
Lower third - mandible

Bones of the Facial Skeleton
Physical Examination
First, inspect face for deformity and
asymmetry
Enophthalmos, proptosis, ocular integrity,
ocular movements
Nasal septum for position, integrity, and
presence of septal hematoma
Epistaxis or CSF rhinorrhea
Physical Examination
Complete neurological exam must be
performed on any patient with suspected
facial trauma
Sensation - test all 3 major branches of the
trigeminal nerve
Motor function - assess facial nerve by
having patient wrinkle forehead, smile, bare
teeth, and close eyes tightly


Physical Examination
Palpation of facial structures - the
infraorbital and supraorbital ridges,
zygoma, nasal bones, lower maxilla, and
mandible
Assess for tenderness, bony deformities,
crepitus, and false motion
Malocclusion or step-off in dentition may
be sign of mandibular fracture

Diagnostic Imaging
Should focus on bony integrity, fluid-filled
sinuses, herniation of orbital contents, and
subcutaneous air
Overall status of the patient, physical exam
findings, and the clinicians initial
impression determine timing and nature of
imaging ordered

Plain films
Traditionally the mainstay in the
radiographic evaluation of facial trauma
Standard plain film facial series: Waters
(occipitomental), Caldwell (occipitofrontal),
and lateral views
Panoramic films are used to best evaluate
mandibular fractures
CT
Offers a viable, cost-effective alternative to plain
films
Very helpful in the evaluation of facial trauma
when facial edema, lacerations, other injuries, or
altered level of consciousness limit usefulness of
clinical exam
Consider institutional wait and turnaround time

MR
Limited role of MR in evaluation of facial
trauma due to insensitivity of MR to
fractures
Used to provide complimentary information
to CT in the evaluation of the eye and its
associated structures
Force of Gravity Impact Required for
Facial Fracture



Bone Force of gravity (g)
Nasal bones 30
Zygoma 50
Angle of mandible 70
Frontal-glabellar region 80
Midline maxilla 100
Midline mandible (symphysis) 100
Supraorbital rim 200


Nasal Fractures
Most common site of
facial trauma due to
location
May be displaced
laterally or
posteriorly
Requires control of
epistaxis and
drainage of septal
hematoma, if present
Zygomatic Fractures
Tripod fracture:
zygomaticofrontal suture,
zygomaticotemporal
suture, and infraorbital
foramen
Present with flatness of
the cheek, anesthesia in
the distribution of the
infraorbital nerve,
diplopia, or palpable step
defect
Maxillary Fractures
Le Fort I maxilla
Le Fort II maxilla, nasal
bones, and medial aspects
of orbits (pyramidal
disjunction)
Le Fort III maxilla,
zygoma, nasal bones,
ethmoids, vomer, and all
lesser bones of the cranial
base (craniofacial
disjunction)
Usually in combination
Mandibular Fractures
Any patient with malocclusion after facial trauma
is assumed to have mandibular fracture until
proven otherwise

Panoramic X-Ray Film of the
Mandible

Note fractures in left angle and right body of mandible
Multiple fractures are present more than 50% of the time
and are usually on contralateral sides of the symphysis