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Emergency Assessment and Treatment: Bony Injuries and Fractures

This document provides guidance on assessing and treating patients with facial trauma. It outlines that the initial focus should be on the airway, breathing and circulation per ATLS principles. For patients with facial or midface bleeding, sitting them forward or on their side can help minimize airway obstruction. Intubation is indicated if the midface and mandible are fractured in a way that displaces the tongue backwards, compromising the airway. Emergency procedures like manually repositioning the maxilla and tongue can help clear the airway until intubation is possible. A surgical airway may be needed if intubation is not possible.

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0% found this document useful (0 votes)
118 views11 pages

Emergency Assessment and Treatment: Bony Injuries and Fractures

This document provides guidance on assessing and treating patients with facial trauma. It outlines that the initial focus should be on the airway, breathing and circulation per ATLS principles. For patients with facial or midface bleeding, sitting them forward or on their side can help minimize airway obstruction. Intubation is indicated if the midface and mandible are fractured in a way that displaces the tongue backwards, compromising the airway. Emergency procedures like manually repositioning the maxilla and tongue can help clear the airway until intubation is possible. A surgical airway may be needed if intubation is not possible.

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EMERGENCY ASSESSMENT AND

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.

Where skull fractures occur in combination with facial


fractures or the fractures extend into the frontal or ethmoidal
sinuses, they are classified as craniofacial, and a joint neurosurgical
and maxillofacial approach is necessary.
If fractures occur at all levels of the face the term panfacial
is utilised. This does not necessarily alter the management of
the individual fracture components, however it does imply a
significant degree of force and one must be suspicious of other
injuries, especially head injuries. As with all trauma patients,
associated injuries, including chest and abdominal trauma,
must be actively excluded.
In considering the bony injuries, the fractures may be displaced
or undisplaced and comminuted or non-comminuted.
In the past, and with particular reference to mandibular fractures,
stability was also considered, however with modern
treatment methods this is a less important factor.
Soft tissue injuries and lacerations
Lacerations are crushing injuries where the soft tissues are
compressed between the underlying bone and some form of
blunt object. Incised wounds are caused by a cutting implement,
such as a knife or glass. Often the injuries are a combination
of the two. Either type of wound can occur with or
without tissue loss. Where the injury results in a communication
between the skin and the mucosa of the oral cavity the
wound is termed ‘through and through’.

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

assessing for neurological deficits, with cervical spine control.


The more detailed secondary survey is aimed at a definitive
examination, with the clear expectation that this will need to
be repeated on several occasions.
The face, head and neck should be inspected and wounds
cleaned and assessed for tissue loss, and then dressed to control
any bleeding not addressed in the primary survey. Their size,
location and depth should be carefully recorded in the case
notes. Large and obvious foreign bodies should be removed
but care should be exercised with penetrating wounds involving
large fragments or blades which potentially penetrate
deep structures. These should be removed in the operating
theatre, in more controlled conditions, after imaging (note
also glass that may injure the assessing surgeon). On occasions
it is helpful to administer local anaesthetic for the examination
and (temporary) repair of facial lacerations, particularly
if a single vessel continues to bleed. In these circumstances it
is very helpful to perform a thorough examination of the key
sensory and motor nerves that may have been injured, before
the local anaesthetic makes this assessment meaningless.
This principle also applies to the management of those
patients for whom intubation is imminent. While this
may be difficult, a brief assessment of Glasgow Coma Scale
(GCS) score, eye function (motility and acuity), facial and
trigeminal nerves and cervical spine pain and function prior
to the induction of anaesthesia can be very helpful in ongoing
management.
Secondary survey
The secondary survey examination should be systematic
because it is easy to be distracted and miss potentially important
injuries that leave only a small external sign, e.g. a small
entry wound from a stabbing to the back of the neck. The
surface inspection should include the back of the neck, the
whole scalp and then move to the frontal view. At this time
it is helpful to perform a formal cranial nerve examination;
of particular importance are cranial nerves II, III, IV, VI, V
and VII.
Further examination
Examination of the eyes should then take place to exclude
globe or retinal injury, as well as to assess acuity, test for diplopia
and assess motility. This is possible even in the most
swollen of eyes because one can gently prise the eyelids apart
with cotton wool buds (or microbiology swabs). These are
held parallel to the eyelids and gently pushed into the oedematous
tissue close to the eyelashes, rotating the swabs to open
the eye. A colleague can then examine the eye.
The position of the globe – whether there is proptosis or
enophthalmos – and visual acuity (utilising a Snellin chart)
in each eye, and whether there is diplopia in all nine positions
of gaze, should be recorded.
The intraoral examination is facilitated by the use of good
light (a headlight is helpful) and suction to allow removal of
blood and saliva. The teeth should be examined and their
presence or absence noted. Dental injuries should be classified.
Teeth may be knocked out in an injury (termed avulsion),
displaced but still attached to soft tissues and/or bone
(termed subluxation) or fractured. If a tooth is mobile it may
be subluxated or have a root fracture (detected on a radiograph).
It is important to account for all missing teeth or
tooth fragments as aspiration of an avulsed tooth or tooth
fragment is a major risk. If there is any doubt about the location
of missing teeth a chest radiograph should be obtained.
If there is a fracture of the mandible, the overlying mucosa
is often torn and there may be an associated haematoma in
the floor of the mouth (Figure 26.4). A key assessment is
that of the dental occlusion (the way in which the teeth bite
together). Patients are able to discriminate tiny alterations in
their occlusion. These occlusal changes may represent dental
injuries or, more commonly, displaced fractures of the maxilla
and/or mandible.
Palpation of the bony contours of the facial bones should
identify sites of tenderness, steps and asymmetry. This can
start at the supraorbital margins, move around the infraorbital
margins and then along the zygomatic arches, moving onto
the condylar heads of the mandible and then running along
the lower border of the mandible.
Investigations
The investigations required fall into two major categories:
first, those required to confirm the provisional and specific
clinical diagnosis with regard to the facial injuries and, second,
those to assess and manage the systemic condition of
the patient.
Systemic investigations will be governed by the general
state of the patient and the past medical history. Typically,
they will include routine laboratory (haematological and biochemical)
investigations and radiological (for example the
cervical spine) and other imaging.
Specific head and neck investigations are utilised and the
general trend is away from plain radiology towards computed
tomography (CT) scanning. If the clinical picture suggests an
isolated mandibular fracture, plain radiographs at right angles
to each other (rotational tomograph, orthopantomogram
(Figure 26.5) and a posteroanterior (PA) mandible) may
suffice, but clinicians should have a low threshold for crosssectional
imaging, particularly if a head or cervical spine CT

is indicated. The additional information from 1 mm imaging


cuts through the facial skeleton is worth the additional radiation
dose, especially if plain radiography has been avoided.
SPECIFIC INJURIES
Mandibular fractures
Mandibular fractures typically occur at specific sites (Figure
26.6). As with all fractures the principles of reduction, fixation,
immobilisation and then rehabilitation apply to facial
fractures. In previous years the reduction and immobilisation
was often achieved by wiring the teeth together, known as
intermaxillary fixation (IMF). However, in recent years this
technique has largely been superseded by the use of open
reduction and internal fixation (ORIF) techniques (Figure
26.7) utilising titanium fixation plates secured with screws.
In general, the facial bones heal well and undisplaced fractures
or those treated with ORIF heal after about 4 weeks.
If the patient has had IMF a liquid diet is required and those
who have had an ORIF procedure must also remain on a very
soft sloppy diet for the same period.
In general, straightforward mandibular fractures treated
with ORIF techniques have 2 mm diameter screws engaging a
single bone cortex (monocortical). These small plates are said
to be load sharing, in that the fractures are reduced and load
is shared between the native bone and the plate. With more
complex or comminuted fractures, larger plates and screws
(up to 2.7 mm diameter) may be utilised; these are termed
fracture or reconstruction plates. They are regarded as load
bearing, and bicortical fixation may also be utilised.

The timing of the definitive treatment of mandibular fractures


is dependent on the general state of the patient; however,
optimal timing is for treatment within 24–48 hours post
injury.
Condylar neck fractures are increasingly being treated
with open reduction and internal fixation techniques, with
better technology and the use of endoscopically assisted surgery.
This can be done via intraoral approaches. Undisplaced
or minimally displaced condylar neck fractures can be treated
non-operatively or with elastic IMF.
Summary box 26.4
Mandibular fractures
●● Mandibular fractures are diagnosed clinically, often because
of deranged dental occlusion
●● Numbness over the distribution of the mental nerve is
common
●● Treatment is primarily with open reduction and internal fixation

Fractures of the zygomatico-orbito


complex (ZMC)
ZMC (malar/cheekbone) fractures are the commonest facial
fractures and have been classified in a variety of different
ways. However, from a clinical perspective, considering the
cheekbone as a four-legged stool is helpful – the four legs are
comprised of the zygomatic arch running anteroposteriorly,
the zygomatic process running vertically (to join the frontozygomatic
process of the frontal bone at the frontozygomatic
(FZ) suture), the infraorbital rim running horizontally and
the maxillary buttress running vertically (Figure 26.8).

With the exception of isolated zygomatic arch, isolated


infraorbital rim and extensively comminuted fractures, if the
ZMC is fractured then all four legs of the stool are fractured
and displacement occurs about two axes, running vertically
through the line from the FZ suture to the maxillary buttress
or running anteroposteriorly along the zygomatic arch.
All ZMC fractures (with the exception of isolated zygomatic
arch and isolated infraorbital rim fractures) involve
the bony orbit, and careful assessment of ocular position and
function is necessary.
On examination there is often periorbital bruising and
swelling and subconjunctival haemorrhage with no posterior
limit is often seen (Figure 26.9). On palpation (or inspection),
bowing or depression of the zygomatic arch may be
detected. Bony steps and tenderness at the frontozygomatic
suture, the infraorbital rim or the zygomatic buttress may
also be detected. Altered sensation over the distribution of
the infraorbital nerve is common, as a result of either direct
trauma or crushing of the nerve as it exits the maxilla or runs
along the orbital floor.
As with mandibular fractures, the role of plain radiography
is diminishing and cross-sectional imaging utilising CT
scanning is the standard investigation except for the simplest
fractures.
In terms of management, the mainstay of treatment is
ORIF with fixation at one of the four ‘legs of the stool’, namely
the frontozygomatic suture, the buttress region, the infraorbital
rim or the zygomatic arch. The necessity for single,
double, triple or four-point fixation will depend on the stability
of the fracture post reduction and the degree of comminution.
Uncomplicated ZMC fractures are generally treated within
10 days of injury.

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

is often infraorbital nerve injury resulting in altered sensation


and, with upper level (Le Fort II and III) fractures, the orbit is
involved to a greater or lesser degree.
The treatment of maxillary fractures, in all but the entirely
undisplaced fractures, involves ORIF techniques utilising a
variety of miniplates (1.5/1.7 mm diameter screws) and/or
microplates (1.0/1.2 mm diameter screws). Fixation is usually
placed along the main facial buttresses (the ‘four legs of the
stool’) for optimal strength and bone quality to be able to
hold the screws (Figure 26.11).
René Le Fort , 1869–1951, French surgeon, classified facial fractures after macabre research in which he dropped
rocks and other heavy objects on the faces of
cadavers.
(a)
(b)
(c)
Figure 26.10 Maxillary fractures as classified by Le Fort. (a)
Le Fort I; (b) Le Fort II; (c) Le Fort III. Figure 26.11 The buttresses of the face.
Summary box 26.6
Maxillary fractures
●● Maxillary fractures indicate significant force transfer – other
associated injuries should be excluded
●● Bleeding from the pterygoid venous plexus may be occult

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

temporarily deformed, causing the buckling and fracturing of


the thin, vulnerable walls. It is likely that both of these mechanisms
have a role in the genesis of orbital fractures.
In any orbital injury the eye must be examined carefully,
even if there is significant swelling. Pupillary response, visual
acuity (utilising a pinhole to correct for missing glasses),
ocular motility and the results of careful ophthalmoscopy
(including the anterior chamber, lens and fundus) should be
documented. Binocular diplopia indicates a motility issue;
however, monocular diplopia suggests a problem within the
globe such as a dislocated lens or retinal detachment.
In general, orbital floor fractures lead to ocular motility
problems, primarily restriction of upgaze due to trapping of
the orbital fat and associated fibrous septae. However, on
occasion the inferior rectus or inferior oblique muscles may
also be trapped. Inferior rectus entrapment is much more
common in children and this needs to be treated as an
emergency because muscle necrosis can occur, leading to
irreversible damage. In these cases the orbital floor appears,
on imaging, undisplaced, i.e. a trap door defect has opened
and then closed again, entrapping the muscle. In addition to
motility problems, orbital wall fractures can lead to changes
in globe position, with dropping of the globe (hypoglobus)
or sinking in of the globe (enophthalmos) (Figure 26.12).
In many cases such changes in globe position are masked in
the immediate postinjury phase by oedema and only become
obvious as this resolves.
A retrobulbar haemorrhage is a surgical emergency
because when left untreated it can lead to blindness. It presents
with decreasing visual acuity, increasing pain, loss of
pupillary response and a tense proptosis. Should this diagnosis
be suspected medical management should be initiated with
acetazolamide, mannitol and steroids; however, the main
treatment is surgical, with lateral canthotomy and cantholysyis
forming the initial intervention.
Investigation of orbital injuries requires CT scanning
(Figure 26.13) but if a retrobulbar haemorrhage is suspected
treatment should be given prior to scanning.
With the exception of retrobulbar haemorrhages and
paediatric orbital fractures, the definitive treatment can be
delayed for 7–10 days (Figure 26.14). This allows oedema
to settle and globe motility and position to be assessed more
accurately. Reconstruction of the orbital rim is usually accomplished
with ORIF techniques and the orbital walls repaired
with autologous materials such as cranial bone or rib grafts,
but proving more popular are preformed titanium implants or
patient-specific custom-made implants.
Figure 26.12 Previously undiagnosed left orbital blow-out fracture,
presenting 3 months after the initial injury. Enophthalmos and lowered
pupillary level are evident.
Figure 26.13 Coronal computed tomography scan showing a left
orbital blow-out fracture, with evident soft tissue herniation into the
maxillary antrum (arrrow).
Figure 26.14 Computed tomography scan showing retrobulbar
haemorrhage and severe proptosis.
Summary box 26.7
Orbital fractures
●● Visual acuity and motility must be assessed
●● In children, orbital floor injuries should be assessed and
treated as emergencies because muscle injury may be
permanent, resulting in reduced ocular motility

Naso-orbito ethmoidal fractures


These central upper midface fractures can range from simple
undisplaced nasal bone fractures to complex comminuted
fractures, impacted into the anterior cranial fossa, in the
region of the cribriform plate. Typically they are caused by
a blow to the bridge of the nose. The more severe fractures
present with periorbital ecchymosis, swelling and nasal bleeding
with the bridge of the nose depressed and the nasal tip
rotated upwards, allowing the nostrils to be seen straight on
(‘piggy nose’). The nasal septum is often disrupted and should
be inspected for haematomas. Cerebrospinal fluid (CSF) may
be seen to be leaking. However, in the initial assessment it is
often difficult to make this diagnosis with any certainty.
Disruption of the attachment of the medial canthal ligaments
can result in traumatic telcanthus – this is due to traumatic
detachment of the ligament from its bony insertion or,
more commonly, comminution of the naso-orbital ethmoidal
complex with the canthal insertion intact, but with a small
fragment of displaced bone.
Investigation is necessary with CT scanning (Figure
26.15) for all but the simplest nasal bone fractures. Treatment
is usually delayed for 7–10 days post injury and generally
necessitates ORIF and repositioning of the fragments
with the medial canthi attached. If a formal canthopexy is
required, this can be achieved with stainless steel wires or specialised
canthopexy wires.
Figure 26.15 Coronal computed tomography scan showing
posteriosuperior impaction of the naso-orbito complex.
Summary box 26.8
Naso-orbito ethmoidal fractures
●● Naso-orbito ethmoidal injuries indicate significant force
transfer
●● Other associated injuries should be excluded, particularly
craniofacial/anterior cranial fossa injuries
Craniofacial fractures
These are fractures that involve the cranial cavity and the
facial bones in continuity. In many cases they involve the
frontal and ethmoidal sinuses, creating a communication
between the cranial cavity and the nasal air sinuses. If this is
combined with a dural tear, CSF will leak into the nose and
is detected as CSF rhinorrhoea with or without a salty taste.
In these circumstances antibiotics are not indicated and the
threshold for surgical intervention is quite variable between
surgeons. The most common site of injury is the posterior
wall of the frontal sinus, however fractures of the ethmoid
and sphenoid sinus can also cause CSF leaks.
Most surgeons would treat persistent leaks lasting 10 days
with surgical intervention, and mostly this is done with an
open anterior fossa repair (necessitating a frontal craniotomy).
In a limited number of cases the CSF leak can be repaired
endoscopically. In most patients the treatment involves cranialisation
of the frontal sinus with obliteration of the frontonasal
duct. Although some surgeons advocate reconstruction of
the posterior sinus wall, others will obliterate the sinus with

fat or bone. Unless there are other pressing imperatives treatment


is usually delayed for 7–14 days.

Summary box 26.9


Craniofacial fractures
●● Usually managed by a multispecialty team involving
neurosurgery, ear, nose & throat (ENT) and oral & maxillofacial
surgery
●● Significant head injuries are common

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.

There are some particular pitfalls: obtaining adequate


cheekbone projection anteroposteriorly while making the
zygomatic arch too prominent, over-impacting the anterior
maxilla, and an anterior mandibular fracture being fixed with
the mandibular angles flared outwards.
Dental injuries
The primary (deciduous) dentition is usually fully erupted by
2.5 years, and the first permanent teeth (lower incisors) usually
erupt at about the age of 6. Between the ages of 5 and 13 the
primary dentition is shed and replaced by the secondary teeth.
If an adult whole tooth is avulsed it should be cleaned gently
in saline and reimplanted; the sooner that this can happen
the better the prognosis (avulsed deciduous teeth are not reimplanted).
This is best achieved under local anaesthesia
and
after irrigation and debridement of the socket. The patient
should then be referred urgently to a dentist for ongoing care;
in many cases the tooth may need to be splinted to immobilise
it and ensure that it is protected from the dental occlusion.
Fractures of the teeth may involve the enamel only, the
enamel and dentine or the enamel, dentine and pulp. Once
the dentine is exposed the fractured tooth can be exquisitely
painful and benefits from a simple dental dressing – in the first
instance local anaesthetic infiltrated in the region of the apex
of the root is helpful in reducing pain pending a specialist dental
assessment. If the pulp is exposed, local anaesthetic applied
topically to the exposed pulp can also give some pain relief.
Wounds involving the eyelid margins and crossing the
vermillion of the lip need special attention to detail and very
careful approximation of all the involved layers such that
referral to a specialist should be considered by the inexperienced
surgeon.
Where there has been skin loss the management depends
on the size of the defect, the elasticity of the surrounding
skin and the circumstances. Small defects can be closed with
direct closure, but for larger defects the mobilisation of local
skin flaps may be necessary. When there is greater tissue loss,
skin grafting and/or free tissue transfer may be required.
Parotid duct
The parotid duct may be damaged as a result of an incised
wound or a crushing injury. This is usually obvious as saliva
leaking into the wound and should this be the case the buccal
branch of the facial nerve is often injured at the same time. If
the duct is transected or damaged this should be repaired over
a cannula inserted into the parotid papilla. This is usually best
achieved with magnification (loupes or microscope) under
the controlled conditions of general anaesthetic.
Facial nerve
Facial nerve injuries are best repaired primarily, and the biggest
challenge to achieving this is not identifying the motor
deficit at presentation. In general, injuries that lie behind a
line from lateral canthus or the eye to the angle of the mouth
are repairable and this should be attempted. Again, this is best
achieved under microscope magnification and a nerve stimulator/
monitor is very helpful in identifying the cut nerve ends.
Animal and human bites
Unlike those elsewhere on the body, facial bites should be
closed primarily and not left open. The abundant blood supply
renders this normal precaution unnecessary. All bites should
be debrided carefully and closed in the usual way; however,
antibiotics, in accordance with local protocols, should be prescribed.
If there is significant tissue loss consideration should
be given to a staged reconstruction.
Summary box 26.10
Dental injuries
●● It is important to account for all missing teeth and/or dental
fragments – a chest radiograph may be indicated
●● Exposed dentine and pulp can be exquisitely painful and
referral for emergency dental treatment can be very helpful
●● Avulsed teeth should be reimplanted as soon as possible

Soft tissue injuries


Lacerations and wounds
Facial lacerations and incised wounds often bleed quite profusely
as a result of the excellent blood supply. This has the
benefit of excellent healing and therefore wounds should only
be debrided of frankly necrotic tissue.
In assessing facial soft tissue wounds it is important to
check the function of the facial nerve and the patency of the
parotid duct because both of these structures require repair
should they be involved in the injury.
Uncomplicated wounds with no tissue loss should be cleaned
and closed in layers under either local or general anaesthesia.
If the skin is contaminated with dirt it should be scrubbed
clean with a brush to prevent dirt tattooing. Usually, absorbable
sutures are utilised intraorally and for the deep layers. It is
important for good closure that the muscle layers are accurately
opposed. The final skin layer should be closed with a monofilament
suture (in children this can be absorbable). For some small
linear incised wounds cyanoacrylate glue can be utilised.
Summary box 26.11
Soft tissue injuries
●● Examination of both motor and sensory nerve function should
be conducted prior to the administration of local anaesthetic
●● Tissue loss can occur and usually warrants specialist referral
●● Careful cleaning (debridement) with removal of all dirt
minimises the chances of wound tattooing

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

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