Soft-Tissue and Skeletal Injuries of the Face

Soft-Tissue and Skeletal Injuries of the Face

Larry H. Hollier Jr.

Patrick Kelley

John C. Koshy

The treatment of the facial trauma patient continues to evolve with progress in imaging, bone fixation technology, and the application of microsurgical reconstructive techniques. Many of the principles of access, reduction, and fixation remain constant, but the application of these principles has been greatly facilitated with improvements in instrumentation and osteosynthesis technology. Facial trauma continues to be treated by a variety of specialists, including plastic surgeons, otolaryngologists, and oral surgeons. Plastic surgeons, however, are uniquely trained to handle the full range of issues present in the trauma patient.


Facial injuries themselves are rarely life threatening, but are indicators of the energy of injury. Initial care of all trauma patients focuses on the algorithmic protocol of ATLS (Advanced Trauma Life Support). Facial injuries should alert the examiner to the possibility of airway compromise, cervical spine injuries, or central nervous system injuries.


Airway compromise is the result of excessive bleeding from an upper airway source, foreign bodies (including aspirated teeth and bone fragments), or direct laryngeal injury. Often, upright positioning with cervical spine protection will improve airway function compromised by excessive bleeding or foreign bodies. Foreign bodies, when present, can also be mechanically removed by the finger-sweep technique. Airway compromise can also occur when the floor of the mouth and tongue lose support from a comminuted mandible fracture and can be alleviated by simple anterior traction on the mandibular symphysis.

The trauma team should have a low threshold for definitive airway protection via endotracheal intubation. The use of blind nasal intubation should be carried out with caution, as the procedure can exacerbate nasal and nasopharyngeal bleeding. Additionally, the tube may be inadvertently placed intracranially in the obtunded patient with a skull base fracture. Endoscopic nasal or oral intubation improves safety by avoiding cervical spine manipulation and further provides immediate confirmation of tracheal intubation.

Emergent tracheotomy is considered in the unusual circumstance of laryngeal fracture or inability to secure an upper airway route to intubation. Tracheotomy performed in the controlled environment of the operating room is far superior to either emergent tracheotomy or cricothyrotomy (also called cricothyroidotomy); however, certain situations will require this emergent procedure, and there should be a low threshold for performing an emergent tracheotomy or cricothyrotomy. There should also be a low threshold for a controlled, temporary tracheotomy procedure, in the patient with significant soft-tissue trauma to the floor of the mouth and tongue, especially the base of tongue, even if the airway appears stable initially. These injuries are more commonly penetrating in nature and initially misleading as there may be minimal early signs of distress. The swelling that develops over the next 24 to 48 hours, however, may be sufficient to compromise the airway, which may result in a tracheotomy under less than favorable circumstances.


The dense vascularity of the head and neck can cause significant blood loss from soft-tissue injuries. Fortunately, most of these injuries allow sufficient access to apply direct pressure and control bleeding. Pressure should be applied accurately and directly, as a number of critical structures can become collateral victims by attempting to clamp sources of bleeding with poor exposure and visualization. Bleeding that cannot be controlled with direct pressure requires packing. Packing in the nasal cavity is usually effective and only rarely requires augmentation with a transnasal balloon catheter in the nasopharynx. These catheters only serve to impede blood from entering the oropharynx where it can more easily enter the lungs. If massive hemorrhage is present, the airway should be managed first by emergent intubation, followed by packing and direct pressure. The source of bleeding is most commonly a branch of the external carotid system, which is most appropriately controlled with angiographic embolization. The radiologist frequently requires the assistance of the surgeon to remove the packing so that the bleeding source can be identified. At this time, and with all cases of significant hemorrhage, type-specific blood should be readily available. Surgical ligation of the external carotid artery is not adequate and will not control bleeding from its injured branches because of the robust collateralization present and should not be attempted (Figure 29.1).

Central Nervous System

Neurologic injury is commonly associated with severe facial trauma. A retrospective study of the National Trauma Data Bank found that the risk of head injury in the setting of isolated facial fractures ranged from 29% to 80%, with increasing rates as the fracture involved more cranial portions of the facial skeleton. In patients with multiple fractures, however, the incidence of head injury becomes more uniform, affecting between 66% and 89% of all cases presenting at major trauma centers. Identifying these injuries is important, as patients with facial trauma rarely die from facial injuries, but can die from associated injuries of the central nervous system. Most patients with facial trauma undergo computed tomography (CT) scanning. The most widely accepted method for expressing the degree of neurologic injury is the Glasgow Coma Score. This evaluates the motor, verbal, and eye-opening responses of the patient on initial evaluation, rating the patient from a lowest score of 3 to a highest score of 15 (Table 29.1).

FIGURE 29.1. Hemorrhage treated by embolization. Patient with gunshot wound to mandible requiring embolization of lingual artery (note coil) to prevent exsanguination. Segmental defect is treated with a distraction device.

As a general rule, concomitant head injury is not a contraindication to facial fracture repair, assuming the neurologic injury is stable and not in the process of evolution. In the event of acute brain injury, the surgical repair of facial fractures generally is delayed to avoid the fluid overload associated with surgery and, most importantly, to avoid undetected decline of neurologic function during the period of general anesthesia when clinical neurologic examination cannot be performed. Once the central nervous system injury and concomitant swelling have stabilized, facial fracture repair can generally be undertaken safely.


Eye opening



To voice


To pain




Verbal response











Motor response

Obeys commands




Withdraws (pain)




Extension (pain)




Glasgow Coma Score (Total)


Facial fractures are also often complicated by cervical spine injuries. In fact, a recent study of the National Trauma Database found that 5% to 8% of isolated facial fractures and 7% to 11% of cases of multiple facial fractures will have an associated c-spine injury.1 Suspicion for injury and vigilant care of the cervical spine are key elements in the care of facial trauma patients. Cervical spine precautions are mandatory until the spine is cleared both clinically and radiographically. For the obtunded patient, the cervical spine is best evaluated with a CT scan, although a negative exam does not rule out unstable ligamentous injury. These patients require additional examination when the sensorium is clear and possibly flexion/extension radiographs or magnetic resonance imaging to definitively evaluate the cervical spine.


Head and Neck Examination

A thorough head and neck examination is performed in a logical and consistent manner to avoid missed injuries. The examination includes the skin, soft tissue, neurovascular structures, and bone. Initially, gross examination identifies skin and softtissue defects and any exposed bone. Next, ecchymoses and soft-tissue swelling serve as red flags for potential underlying injury and are used with information regarding the mechanism of injury to develop a level of suspicion about the underlying injuries. Bony structures should be palpated in a systematic fashion to identify tenderness, deformity, or step-offs. In the acutely injured patient with facial trauma, however, the physical exam is greatly impaired by facial swelling, and facial asymmetries secondary to fractures are usually concealed. Additionally, it may be difficult to elicit tenderness because of simultaneous distracting injuries. The examiner must not be misled by more impressive injuries and overlook less obvious but potentially significant problems.

The examiner then carefully assesses the patient for neurologic deficits, including the trigeminal and facial nerves. Sensory disturbances in the forehead, cheek, and lower lip should be well documented, as should any deficits in facial nerve function. Nerve injuries that are not documented preoperatively may be attributed postoperatively to surgical intervention. Lacerations, contusions, and abrasions of the skin may focus the exam by indicating which nerves are at risk.

Much of the long-term morbidity of facial trauma is associated with ocular and orbital injury. Although there should be a low threshold to involve the ophthalmologist, the physician treating facial trauma should be well versed in the ocular examination. A complete ocular examination includes the evaluation of ocular history, acuity, light and red light perception, ocular motility, pupillary exam, and examination of the conjunctiva and eyelids. Each eye requires assessment individually.

Examination of the oral cavity is essential, especially in the obtunded patient who may have loose teeth, bone fragments, or foreign bodies. Identification and removal of prosthetics (e.g., dentures) is essential. The occlusion and intercuspation are carefully evaluated, as both mandibular and maxillary fractures can result in malocclusion. Patients are capable of sensing the slightest change in their occlusion. Even in patients with unusual bites, careful analysis of the wear facets may enable the surgeon to determine if an underlying malocclusion is present.

Proper record keeping of facial injuries includes rough sketch drawings in the medical chart and photographs to document injuries. These photographs may prove invaluable in the treatment of secondary deformities and can also be beneficial in medicolegal disputes. As such, photographic consents
should routinely be obtained as part of the treatment consent upon entrance to the emergency department.


In almost all patients with facial trauma, CT scanning is performed and is acceptable for the diagnosis of essentially all facial fractures. The scan is performed with axial cuts no greater than 3 mm apart, from the top of the cranium through the bottom of the mandible. Additionally, in cases of complex facial trauma, it is helpful to have a three-dimensional reconstruction of the facial skeleton formatted so as to provide for a better overall orientation.

The one area where the CT scan may not be entirely sufficient is the mandible. Although the CT is essentially 100% sensitive and specific for the fractures, it does not give detailed information about dental structures. This is most critical in the region of the mandibular angle with respect to the condition of the second and third molars. Information regarding root damage and tooth position relative to the fracture affects the planning and treatment of angle fractures and is necessary to achieve optimal outcomes. For more detailed information regarding these variables, a panoramic radiograph is extremely beneficial. These radiographs evaluate the entire mandible, from condyle to condyle, in a single image and provide excellent detail of the condyles and dentition. Several downsides exist, though. First, the more commonly used panoramic devices require upright positioning and cervical spine clearance to be used, although certain less common devices allow the patient to be imaged while supine. Additionally, care must be taken when interpreting fractures based solely on a panoramic radiograph of the mandible, especially the symphysis and parasymphysis, as distortion of these regions can be misleading. In these cases, a supplemental posteroanterior film of the mandible complements the panoramic image by providing additional detail of the region. Lateral radiographs and/or CT scans can provide additional information about the regions posterior to the parasymphysis (Figure 29.2).


Orbital Fractures

Orbital Examination.

In patients with trauma involving the orbit, a thorough examination of the globe and associated structures is performed. If the patient has had previous iatrogenic globe penetration, such as cataract surgery or radial keratotomy, the risk of globe rupture following trauma is substantially increased. A visual examination is then performed, including an exam of the visual fields. Any damage to the optic nerve may manifest first as a limitation in the visual field rather than a significant change in gross acuity.

Additionally, one should test for color desaturation. The first indication of optic nerve compression may be red color desaturation. The easiest way to test this in the emergency department is to dim the lights and hold a penlight up to the finger. The light through the skin appears red. The patient should be asked with alternate eyes closed whether there is any difference in the intensity of the red color between the two eyes.

Direct and consensual pupillary responses are elicited to determine the function of the second and third cranial nerves. Anisocoria may be an indication of second or third nerve damage, or direct trauma to the iris. An afferent pupillary defect is indicative of optic nerve injury and can be elicited by a swinging flashlight test. Range-of-motion testing of each eye will determine the function of the third, fourth, and sixth cranial nerves. Restrictions in the range of motion of the globe should be confirmed with a forced duction test to determine if the restriction is caused by mechanical entrapment or by injury to the nerves or muscles. These emergency department maneuvers, although potentially quite informative, are no substitute for a thorough dilated exam by an ophthalmologist. Ophthalmologic consultation should be considered in every case of orbital trauma.

Indications for Surgery: Orbital Floor.

Indications for the repair of orbital fractures are an area of controversy. Mechanical entrapment of an extraocular muscle may be demonstrated on forced duction testing or on imaging studies and is an indication for surgical repair. A second surgical indication is evidence of enophthalmos. With the initial swelling present secondary to the trauma, any enophthalmos that is manifest indicates a significant deformity as it would be expected to worsen with the resolution of swelling. Deferring surgery will complicate the eventual repair that is required.

Defect size is the most controversial parameter in determining the indication for surgery. Various authors have used different guidelines.2 Many believe that any defect greater than 1 cm2 benefits from surgical repair because of the likelihood of subsequent enophthalmos. Other authors have tried to quantitate, via CT imaging, the actual increase in orbital volume compared with the uninjured side. This volume is then used to assess the risk of postinjury enophthalmos. Currently, there are no firm data confirming the usefulness of this approach.

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Jun 26, 2016 | Posted by in General Surgery | Comments Off on Soft-Tissue and Skeletal Injuries of the Face
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