Plastics – Facial Injuries: By Tara Lynn Teshima M.D.
Patients with facial injuries often have multi-system trauma. As such, your initial assessment should follow the ATLS (or Advance Trauma Life Support) protocol. First and most importantly, assess the airway of the patient. Facial injuries increase the risk of upper airway obstruction from swelling, broken teeth, and/or uncontrolled bleeding. An obstructed airway can be fatal and managing this should take precedence. After the airway has been protected, the second most important thing in relation to facial injuries is to clear the C-spine both clinically and radiologically and to rule out a skull fracture.
Basal skull fractures can lead to significant intracranial trauma, which can be life threatening. In addition, the operative management of facial injuries requires manipulating the head. Making sure there is no C-spine injury prior to surgery is vital to the safety of the patient. Once the patient is stable, assess the extent of the facial injury and develop an appropriate management plan. For simplicity, there are 2 components to facial injuries: soft tissue and bone.
If there are any facial lacerations they should always be cleaned and sutured closed. With regards to bone, think of the face as a puzzle with 5 main bony pieces – the nose, zygoma and orbit, mandible, maxilla, and the frontal sinus and skull. The most frequently fractured piece is the nasal bone. If you see a patient with nasal fracture and septal hematoma, always drain the hematoma. Not doing so can increase the risk of septal necrosis and perforation. Nasal bone fractures can often be treated by performing a closed reduction and nasal packing. Zygoma fractures are the second most common facial fracture. These are often due to direct trauma.
Don’t forget to assess vision. Most of these patients will also have concurrent ocular injuries. If the patient has an orbital floor fracture make sure there is no entrapment of the inferior rectus muscle.
Entrapment is a clinical diagnosis and the patient is unable to elevate the eye. This is a rare surgical emergency more commonly seen in the paediatric population. Mandibular fractures occur less commonly, but carry the increased risk of airway obstruction secondary to swelling and teeth displacement. Fractures of this bone can cause malocclusion, numbness in the V3 distribution of the trigeminal nerve, and temporomandibular joint problems. If malocclusion is present, prepare for early surgical intervention.
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