Emergency Assessment and Treatment: Bony Injuries and Fractures
Emergency Assessment and Treatment: Bony Injuries and Fractures
TREATMENT
The management of a patient with facial trauma must begin with an immediate
assessment of the airway, breathing and circulation in keeping with the advanced
trauma life support (ATLS) principles.
If the patient has facial or midface bleeding they may sit forward or be placed on
their side (Figure 26.1) to minimise the risk of blood and/or dental fragments
obstructing the airway.
The use of good light and high volume suction is often helpful.
The midface, when fractured, is displaced downwards and backwards
(Figure 26.2), and if this occurs in combination with a mandibular fracture,
particularly if the anterior mandible is comminuted, the tongue is
also displaced downwards and backwards, adding to the
airway compromise and creating the risk of obstruction
(Figure 26.3).
In these circumstances intubation is indicated, but
emergency procedures can be employed to buy time.
In the obtunded or unconscious patient the maxilla can be
grasped by hand, disimpacted and pulled forwards. In addition, the tongue can be
pulled forwards and held forwards, with a large suture or towel clip, to help clear the
airway.
If intubation is not possible a surgical airway is indicated.
Massive, life-threatening bleeding is usually only seen in the context of major trauma,
lacerations, blast, ballistic, penetrating or gunshot injuries.
Significant bleeding, usually from the pterygoid venous plexus and/or the rich blood
supply of the nose, can be seen in central midface injuries.
Management of massive midface bleeding may require intubation and the placement
of anterior and or posterior nasal packs. There are specific inflatable nasal balloons
that can facilitate the immediate management, however Foley catheters may also be
utilised. Once the patient has been stabilised a more formal assessment may be
performed.
CLASSIFICATION OF FACIAL
INJURIES
Bony injuries and fractures
The facial skeleton can be divided into thirds vertically:
●● upper face (from level of canthi upwards);
●● midface (from maxillary teeth to canthi);
●● lower face (mandible and mandibular teeth).
In addition, the midface can be divided into central and
lateral portions. The central midface is the naso-orbital–
ethmoidal complex and the lateral portion comprises the
maxillary complex).
The eye socket can be considered as a separate entity,
because orbital fractures can occur in isolation or as part of a
constellation of multiple fractures. Orbital fractures can affect
the orbital floor, medial and/or lateral walls and the roof of
the orbit.
CLINICAL ASSESSMENT
History
As with all aspects of surgical diagnosis, the history is paramount.
As much information as possible should be obtained
about the mechanism of injury, the past medical history and
the postinjury course. This will be directly from the patient,
friends, family, witnesses and emergency services.
Knowledge of the mechanism of injury will often help to
identify the potential occult injuries that are not obvious on
first inspection. As the craniofacial region is so richly vascularised,
the often dramatic appearance seen in major facial
trauma has the potential of distracting the unwary clinician
from potentially more important injuries.
Examination
Primary survey
Initially, the primary survey is aimed at the airway: controlling
bleeding, restoring and maintaining the circulation and
Maxillary fractures
Maxillary fractures are traditionally classified after René Le
Fort’s work, in which he recreated the maxillary fractures utilising
cadavers and a sandbag. Interestingly, the numbering, in
modern usage, has become reversed from the original: the Le
Fort I fracture being inferior and the Le Fort III being superior
(Figure 26.10). While the classification is simple, real life presentations
are often not. CT scanning and the use of open surgical
techniques have demonstrated that the described patterns
are not often adhered to and that comminution is the norm.
Midface fractures are often accompanied by significant
facial swelling and this makes palpation of the skeleton difficult.
The characteristic finding is of a mobile maxilla which
tends to be displaced backwards and inferiorly. This can compromise
the airway (see above) and results in an anterior
open bite (inability to close the front teeth together). There
Orbital fractures
The bones that comprise the orbit can be fractured and, in
order of frequency, the floor, medial wall, lateral wall and roof
may be disrupted either in combination or as isolated injuries.
The mechanism of this is unclear and, particularly with
isolated injuries, it may be that a rapid increase in pressure
within the confined space of the orbit, typically, for example,
when a squash ball hits the eye, results in fracture of the
very thin floor and/or medial wall. Alternatively, forces are
transmitted from the outer bony orbital rim, which is possibly
Panfacial fractures
In cases where there are fractures at all levels of the facial
skeleton (upper, mid and lower face) the term panfacial fracture
is used, and these fractures can present particular management
challenges. First, multiple-level fractures indicate
a significant amount of force and therefore energy transfer,
hence associated injuries to the brain, cervical spine and
other organs are much more common. Second, reconstruction
of the multiple fractures is much more difficult because
there is little normal anatomy to act as a guide. Each component
of the panfacial fracture is treated in the same way
as an isolated fracture would be, but sequencing the repair
is challenging. The options are top down (craniofacial, zygomatico-
orbital, maxillary and finally mandibular), bottom up,
inside out (starting centrally and working laterally) or outside
in. Most surgeons experienced in managing this type of injury
would tailor the sequence to the particular fracture pattern to
optimise the use of normal or near normal anatomy as a guide.
FURTHER READING
Brennan P, Schliephake H, Ghali GE, Cascarini L. Maxillofacial surgery,
3rd edn. London: Churchill Livingstone, 2017.
Fonseca R, Barber HD, Powers M, Frost DE. Oral and maxillofacial trauma,
4th edn. Philadelphia: Saunders, 2012.
Perry M, Holmes S. Atlas of operative maxillofacial trauma surgery: primary
repair of