Facial trauma causes significant of morbidity in the United States. With injuries varying widely, the clinical benefits of antibiotics use in facial fracture treatment are not easily determined. The pediatric population is more predisposed to craniofacial trauma secondary to their increased cranial mass to body ratio. All patients with traumatic injury should be assessed according to the Advanced Trauma Life Support protocol. This article discusses the types and prevalence of injuries and approaches to management.
Key points
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Facial trauma is a significant cause of morbidity in the United States.
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With injuries varying widely in fracture location, severity, and wound contamination, the clinical benefits of antibiotics use in facial fracture treatment are not easily determined.
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The pediatric population is predisposed to craniofacial trauma more so than the adult population secondary to their increased cranial mass to body ratio.
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Every patient with a traumatic injury should be assessed according to the Advanced Trauma Life Support protocol.
Epidemiology
Facial trauma is a significant cause of morbidity in the United States. Estimated annual costs due to emergency department visits alone approach $1 billion per year. Trauma care is associated with low reimbursement by federal agencies, placing an economic burden on major trauma centers in the United States. Erdmann and colleagues reported on operative facial fracture management at a single academic medical center and the financial impact on the health system. The presented data confirmed a lower professional collection rate for operatively managed facial trauma in a representative US tertiary medical center compared with overall professional collection rates by the Division of Plastic and Reconstructive Surgery, Duke University Medical Center (33%) and compared with the overall collection rates for orthopedic surgery, including skeletal trauma management (32%).
National data from 2004 confirm that approximately 70% of patients with facial and skull fractures are managed in teaching institutions ( http://hcup.ahrq.gov/HCUPnet.asp ). VandeGriend and colleagues recently published a retrospective review of all nonpediatric inpatient and outpatient facilities of the Detroit Medical Center (DMC) from 1990 to 2011 and weighted national inpatient estimates from 1993 to 2010 using the National Inpatient Survey. DMC records identified 30,260 adult facial fractures. These included nasal (30.1%), mandible (22.7%), malar-maxillary (15.4%), orbital floor (15.7%), and other (16.1%) fractures. A total of 8528 fracture repairs were performed, including nasal (17.1%), mandible (41.6%), malar (15.2%), maxillary (6.4%), and other (19.6%). Overall, from 1990 to 2011, fractures increased. Scaled and unscaled national data were very similar and showed no significant differences in trend. In an epidemiologic study of facial injuries by Walker and colleagues, men were more often injured than women (68% compared with 32%). Half of all patients were between 15 and 45 years old. Falls (39%) and sport activities (29%) were the most common causes. Fractures accounted for 25% of presentations. Fractures of the nose (50%), mandible (25%), and zygoma (12%) were the most common sites of injury.
Van Hout reported on 394 patients with facial fractures requiring an operation in a Dutch trauma center. Intoxication was documented in 15% of patients, usually with alcohol (91%). The male-to-female ratio was 3:1 with a peak incidence in young men (35% of fractures). Motor vehicle accidents (MVAs) accounted for 42%. Interpersonal violence and sports led to more injuries in men than in women, and mandible and zygomatic fractures accounted for more than 80% of the total. O’Meara and colleagues found that patients with facial fractures were more likely to need an operation if they had consumed alcohol within the preceding 8 hours or were victims of interpersonal violence. McAllister and colleagues found that 47% of those admitted for facial injuries had evidence of illegal drugs in their urine. Cannabinoids and benzodiazepines were most often detected. Both alcohol and drugs were found in 17% of cases, although 72% of patients with positive toxicology results denied substance abuse. An unreliable substance abuse history naturally has implications for general anesthesia and analgesia. Patients with facial injuries often have associated head and extremity injuries that can prolong their hospital stay. In a review of the management of traumatic brain injuries, Tsang and Whitfield reported that 24% of patients with craniofacial fractures also had fractures in the base of the skull, which were complicated by the leakage of cerebrospinal fluid in 20%.
Children account for approximately 14% of all facial fractures. Although facial fractures are less common in the pediatric population than in adults, they are still known to be a substantial source of morbidity, mortality, and resource utilization. Imahara and colleagues reported that children with facial fractures have more severe head and chest injuries, longer lengths of hospital and intensive care unit stays, higher hospital charges, and higher mortality rates compared with other pediatric trauma patients without facial fractures. Soleimani and colleagues analyzed fractures in 21,533 pediatric patients. They found that for all age groups, the top 3 trauma mechanisms of pediatric facial fractures that resulted in hospitalization were MVA, intentional trauma (IT), and falls (43%,17%, and 11% of patients, respectively). MVA was the most frequent mechanism for all age groups. For patients younger than 10 years old, falls were more common than IT; whereas for patients 10 years and older, IT injuries were more common than falls. The incidence of inpatient facial fractures due to MVA and IT increased with age. The incidence of inpatient pediatric facial fractures due to MVA in the United States decreased from 5.7 to 4.4 per 100,000 from 2000 to 2009. This decrease may indicate that vehicle restraints may be keeping children safer or that parents are more compliant with child vehicle restraint laws. Use of safety devices, including seatbelts and airbags, is associated with a decreased incidence of facial fractures. There was a significant increase in the number of inpatient pediatric facial fractures due to IT and fall with most patients being male (70%). African American and Hispanic patients accounted for most patients in the IT group and came from the poorest neighborhoods. Most of the patients were admitted to large (68%), urban (94%), and teaching (75%) hospitals. The mandible was the most commonly fractured bone (32.2%). Multiple facial fractures were seen in 24% of patients. Nasal, zygomatic, and maxillary, and orbital floor fractures occurred in 13.8%, 6.3%, and 8.3% of patients, respectively. Concomitant injuries occurred in 58.8% of patients. Intracranial injuries and/or skull fractures (45.1%), cervical spine (2.2%), thoracic (15%), abdominopelvic (10.9%), and extremity (20.3%) injuries were all associated with facial fractures. The overall mortality rate was 2%.
Epidemiology
Facial trauma is a significant cause of morbidity in the United States. Estimated annual costs due to emergency department visits alone approach $1 billion per year. Trauma care is associated with low reimbursement by federal agencies, placing an economic burden on major trauma centers in the United States. Erdmann and colleagues reported on operative facial fracture management at a single academic medical center and the financial impact on the health system. The presented data confirmed a lower professional collection rate for operatively managed facial trauma in a representative US tertiary medical center compared with overall professional collection rates by the Division of Plastic and Reconstructive Surgery, Duke University Medical Center (33%) and compared with the overall collection rates for orthopedic surgery, including skeletal trauma management (32%).
National data from 2004 confirm that approximately 70% of patients with facial and skull fractures are managed in teaching institutions ( http://hcup.ahrq.gov/HCUPnet.asp ). VandeGriend and colleagues recently published a retrospective review of all nonpediatric inpatient and outpatient facilities of the Detroit Medical Center (DMC) from 1990 to 2011 and weighted national inpatient estimates from 1993 to 2010 using the National Inpatient Survey. DMC records identified 30,260 adult facial fractures. These included nasal (30.1%), mandible (22.7%), malar-maxillary (15.4%), orbital floor (15.7%), and other (16.1%) fractures. A total of 8528 fracture repairs were performed, including nasal (17.1%), mandible (41.6%), malar (15.2%), maxillary (6.4%), and other (19.6%). Overall, from 1990 to 2011, fractures increased. Scaled and unscaled national data were very similar and showed no significant differences in trend. In an epidemiologic study of facial injuries by Walker and colleagues, men were more often injured than women (68% compared with 32%). Half of all patients were between 15 and 45 years old. Falls (39%) and sport activities (29%) were the most common causes. Fractures accounted for 25% of presentations. Fractures of the nose (50%), mandible (25%), and zygoma (12%) were the most common sites of injury.
Van Hout reported on 394 patients with facial fractures requiring an operation in a Dutch trauma center. Intoxication was documented in 15% of patients, usually with alcohol (91%). The male-to-female ratio was 3:1 with a peak incidence in young men (35% of fractures). Motor vehicle accidents (MVAs) accounted for 42%. Interpersonal violence and sports led to more injuries in men than in women, and mandible and zygomatic fractures accounted for more than 80% of the total. O’Meara and colleagues found that patients with facial fractures were more likely to need an operation if they had consumed alcohol within the preceding 8 hours or were victims of interpersonal violence. McAllister and colleagues found that 47% of those admitted for facial injuries had evidence of illegal drugs in their urine. Cannabinoids and benzodiazepines were most often detected. Both alcohol and drugs were found in 17% of cases, although 72% of patients with positive toxicology results denied substance abuse. An unreliable substance abuse history naturally has implications for general anesthesia and analgesia. Patients with facial injuries often have associated head and extremity injuries that can prolong their hospital stay. In a review of the management of traumatic brain injuries, Tsang and Whitfield reported that 24% of patients with craniofacial fractures also had fractures in the base of the skull, which were complicated by the leakage of cerebrospinal fluid in 20%.
Children account for approximately 14% of all facial fractures. Although facial fractures are less common in the pediatric population than in adults, they are still known to be a substantial source of morbidity, mortality, and resource utilization. Imahara and colleagues reported that children with facial fractures have more severe head and chest injuries, longer lengths of hospital and intensive care unit stays, higher hospital charges, and higher mortality rates compared with other pediatric trauma patients without facial fractures. Soleimani and colleagues analyzed fractures in 21,533 pediatric patients. They found that for all age groups, the top 3 trauma mechanisms of pediatric facial fractures that resulted in hospitalization were MVA, intentional trauma (IT), and falls (43%,17%, and 11% of patients, respectively). MVA was the most frequent mechanism for all age groups. For patients younger than 10 years old, falls were more common than IT; whereas for patients 10 years and older, IT injuries were more common than falls. The incidence of inpatient facial fractures due to MVA and IT increased with age. The incidence of inpatient pediatric facial fractures due to MVA in the United States decreased from 5.7 to 4.4 per 100,000 from 2000 to 2009. This decrease may indicate that vehicle restraints may be keeping children safer or that parents are more compliant with child vehicle restraint laws. Use of safety devices, including seatbelts and airbags, is associated with a decreased incidence of facial fractures. There was a significant increase in the number of inpatient pediatric facial fractures due to IT and fall with most patients being male (70%). African American and Hispanic patients accounted for most patients in the IT group and came from the poorest neighborhoods. Most of the patients were admitted to large (68%), urban (94%), and teaching (75%) hospitals. The mandible was the most commonly fractured bone (32.2%). Multiple facial fractures were seen in 24% of patients. Nasal, zygomatic, and maxillary, and orbital floor fractures occurred in 13.8%, 6.3%, and 8.3% of patients, respectively. Concomitant injuries occurred in 58.8% of patients. Intracranial injuries and/or skull fractures (45.1%), cervical spine (2.2%), thoracic (15%), abdominopelvic (10.9%), and extremity (20.3%) injuries were all associated with facial fractures. The overall mortality rate was 2%.
Perioperative antibiotic and steroid prophylaxis
The role of antibiotics in facial fracture treatment remains controversial. With injuries varying widely in fracture location, severity, and wound contamination, the clinical benefits of antibiotics use are not easily determined. The literature has tried to distinguish between antibiotic use in mandible fractures and antibiotics with other facial fractures, including isolated condylar fractures. Surgeons agree on the need for antibiotics with infected wounds and most routinely administer antibiotics in the perioperative setting.
In 2006, Andreasen and colleagues conducted a systematic review. The reviewers concluded that prophylactic antibiotics are beneficial in the treatment of mandible fractures but, because of a low risk of postoperative infection, prophylactic antibiotics were not indicated for other facial fracture sites. No benefit of prophylactic antibiotics in maxillofacial fractures, including mandible fractures, was found by Kyzas, Miles and colleagues, Shridharani and colleagues, and Knepil and Loukota. Morris and Kellman summarized the available literature and recommended that antibiotics should only be given for mandible fractures from injury until completion of the perioperative course but not postoperatively. There are insufficient data to assess prophylactic antibiotics in nonmandible fractures and isolated condyle fractures but existing evidence demonstrates no benefit to postoperative antibiotics.
There is controversy about whether antibiotics should be routinely given to patients with skull base fractures in an effort to prevent infectious complications, including meningitis. In 2015, Ratilal and colleagues published a Cochrane review of randomized controlled trials (RCTs), as well as non-RCTS, concerning antibiotics and skull base fractures. There was insufficient evidence for prophylactic antibiotic use in patients with skull base fractures with or without a cerebrospinal fluid leak. Until better evidence becomes available, the routine use of antibiotics in these cases should be avoided.
Glucocorticoids are often used to reduce airway edema, although evidence for this benefit is largely limited to children postextubation. The Corticosteroid Randomization After Significant Head injury (CRASH) study identified an excess mortality in the presence of head injury if high-dose methylprednisolone is administered ; therefore, it should be avoided. This may have implications in the management of some vision threatening injuries. Similarly, the routine administration of high doses of steroids for early spinal cord injury is controversial and, despite having been advocated by Advanced Trauma Life Support (ATLS) protocol, has been questioned based on its lack of efficacy and significant complications.
Pediatric trauma
The pediatric population is predisposed to craniofacial trauma more so than the adult population secondary to their increased cranial mass to body ratio. This translates to higher energy insults to the pediatric craniofacial skeleton. Though the relatively increased size of the pediatric cranium is a larger target, it also provides several protective features. The pediatric skeleton is more flexible because of its immaturity and incomplete calcification. The presence of tooth buds increases the tooth to bone ratio and contributes to the mandibular and maxillary flexibility and stability. The cranium to face ratio of the pediatric patient is 8:1 compared with 2:1 in adults. This increased cranial to face ratio decreases the risk of maxillofacial injury. The facial fat pads confer additional protection to that age group.
The frontal bone is prone to fracture in children because of its relative size. Orbital roof fractures are more common in children younger than 7 years of age before frontal sinus pneumatization. After 7 years of age, orbital fractures more often involve the walls and floor. The midface becomes more susceptible to fracture as it enlarges and becomes more protrusive with age. These fractures are often the result of significant force. Mandible fractures are common in children and often are incomplete (Greenstick fractures). Le Fort fractures are complex fracture patterns that result from high-energy insults and are fortunately uncommon. Fracture location, complexity of injury, associated injuries, as well as patient’s age and time since injury determine fracture management. The pediatric facial skeleton has increased osteogenic potential. This translates into a more rapid rate of healing necessitating earlier intervention and shorter duration of immobilization.
In the past, the concern for interference with the growth and development of the pediatric facial skeleton prompted a minimalist approach in the management of pediatric facial fractures. Closed reduction and maxillomandibular fixation (MMF) were initially the treatment method of choice for all displaced facial fractures. Now, open reduction and internal fixation (ORIF) is the preferred treatment of most facial fractures in pediatric patients with mixed and permanent dentition. ORIF allows fixation in 3 dimensions. No or less time is spent in MMF, thus decreasing airway risk and improving nutrition and tolerance. Unfortunately, disruption of the periosteum and the vascular supply, as well as the creation of scars, may interfere with future growth of the affected area.
Evaluation of facial trauma
Every patient with a traumatic injury should be assessed according to the ATLS protocol. After life-threatening conditions are stabilized, the patient is cleaned and the face is examined. The face is assessed in thirds for neurovascular integrity, fractures, and lacerations. A screening eye examination should be performed (pupillary light reflex, extraocular movements, globe position, and visual acuity). An intranasal examination should eliminate a septal hematoma. Changes in occlusion should be noted. Attention is then directed to the examination of the scalp, ears, and neck (lacerations, hematoma, foreign body). Imaging is directed by the primary survey, mechanism of injury, and suspected injuries. Facial fractures are evaluated by computed tomography (CT) scan, and 3-dimensional CT reconstructions may be helpful. In case of suspected vascular injuries in penetrating neck injuries in zones I and III, CT angiography is recommended.
Soft tissue injuries and management
Lacerations and Avulsions
Wounds should be irrigated thoroughly with sterile saline or antibiotic solution, have debris removed, and be closed primarily. Debridement should be very conservative. Large soft tissue defects not amenable to primary closure should be dressed with a wound vacuum-assisted closure (VAC) dressing to promote healing by secondary intention. Avulsed tissue may be beneficial at its native site, either as viable tissue that heals primarily or as temporary biological dressing. Application of a moisturizing ointment, applied twice daily for 1 to 2 weeks, promotes wound healing. Permanent sutures should be removed within 5 to 7 days. Aesthetically unacceptable scars can be revised in 6 to 9 months.
The Facial Nerve and Parotid Duct
Facial nerve function should be assessed and documented according to the House-Brackmann grading scale. Most penetrating injuries in the distribution of the facial nerve with incomplete facial paralysis do not require surgical intervention. Injuries lateral to the lateral canthus with complete facial paralysis should be explored. In blunt and blast injuries with associated facial paralysis, the temporal bone should be evaluated. Facial lacerations with facial nerve paralysis should be explored within 72 hours of injury because the distal nerve segment can still be identified through electrical stimulation with a probe. If the nerve is transected, the proximal and distal ends of the nerve should be mobilized to allow for a tension-free epineural repair. Nerve interposition grafts may be necessary. Neurotrophins and neurokinins, such as resveratrol and oxytocin, may add in facial nerve regeneration.
Blood at the orifice of the parotid duct (Stenson duct) should prompt cannulation of the duct with a lacrimal probe to assess duct integrity. If injury to the duct is identified, the duct is closed over a silicone elastomer stent. The stent may be left in place for several weeks to divert saliva and prevent stenosis of the duct. If there is injury to the more distal duct it should be reimplanted into the papilla or into the buccal mucosa at a more posterior location. A drain should be placed in the wound bed to evacuate residual blood or saliva and prevent sialocele formation.
Bites: Human and Canine
Bite wounds should be washed out and primarily closed if possible. Antibiotics administered should cover Staphylococcus aureus , Streptococci , Pasteurella multocida , Eikenella corrodens , Corynebacterium spp, and other anaerobes. The rabies status of the animal should be determined and the patient immunized if indicated. Human bites are associated with increased pathogenicity and potential for transmission of infection. Hepatitis B and C, herpes simplex virus, syphilis, tuberculosis, tetanus, and human immunodeficiency virus are transmissible through human bite injuries.
Fractures
Frontal Sinus Fractures
Because of the low incidence, management of these fractures has not been investigated by prospective clinical trials. Thus there is no consensus for surgical indications, surgery timing, method of repair, or postoperative surveillance for frontal sinus fractures. Frontal sinus fractures are traditionally treated with observation for minimally displaced anterior table fractures. They are explored and reduced for more displaced fractures of the anterior table. Frontal sinus obliteration is reserved for fractures involving the nasofrontal duct, whereas frontal sinus cranialization is performed for fractures of the anterior table with cerebrospinal fluid leakage or significantly displaced or comminuted posterior table fractures. Typically, an existing laceration or a bicoronal incision is used to gain access to the frontal sinus. The traditional obliteration and cranialization techniques are increasingly replaced by endoscopic surgery techniques with less morbidity ( Fig. 1 ).
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