2. Injuries to the facial region-blunt and penetrating.

Question 1

Injuries to the facial region - Define

Answer 1

Blows to the face can compromise the airway, cause injury to the head/cervical spine

Question 2

Injuries to the facial region - Etiology

Answer 2

Violence

snow + freezing weather

RTA

Question 3

Injuries to the facial region - Clinical Presentation

Answer 3

• Pain, bruising, oedema (feature of all fractures – develops within 60-90mins – not immediately: impairs airway – swelling of tongue, facial + pharyngeal tissues)
• Visible lacerations, injuries to brain/cervical spine

Question 4

Injuries to the facial region - Examination of pt:

Answer 4

• Facial injury can distract whole body examinations
• Rapid onset of edema can compromise examination – edema of eyelids = difficulty to examine pupils
• Tenderness = potential fracture
• Asymmetry
• Cranial nerves: paraesthesia suggests fracture proximally along course of nerve
  o Facial palsy, low visual acuity, damage to floor of orbit – CN3,4,6 – diplopia

Question 5

Injuries to the facial region - Diagnostic Investigations

Answer 5

X-ray

CT

Question 6

Fracture of facial skeleton - Classification

Answer 6

Fort classification: Divided into 3

• Upper 1/3 (transverse)= above eyebrows: fracture occur at point of weakness = sutures, foramen, thin bone
• Middle 1/3 (pyramidal) = above mouth: pattern of fracture related to type of trauma – blunt/sharp
• Lower 1/3 (craniofacial dysfunction) = floating face, complete separation of facial bones

Question 7

Fracture of facial skeleton - Types

Answer 7

Zygomatic fracture

Blowout fracture of orbit

Naso ethmoidal complex fracture

Fractures of mandible

Question 8

Fracture of facial skeleton - Zygomatic fracture -

Main Point

Treatment

Answer 8

Most common of middle 1/3 of face. Damage to infraorbital n = numbness of cheek

Treatment

• Fracture reduced by gillies temporal approach
  1. Incision in hairline, superficial to temporal fossa
  2. Channel made down to body of zygomatic bone

Bristows or Roew’s elevator inserted beneath body of zygoma + force applied in opposite direction to displacement of fracture

a. If unstable fracture = ORIF

Question 9

Blowout fracture of orbit -

Main Points

Treatment

Answer 9

• Direct trauma to globe of eye can push it back within the orbit – blunt objects
• Weakest part = floor of orbit – orbital contents can (necrosis of tissue) herniate into maxillary antrum = muscular dysfunction

Treatment
Bone graft to repair orbital floor

Question 10

Naso ethmoidal complex fracture

Main Points

Answer 10

• Involves nasal bones, frontal process of maxilla, medial + infraorbital rims + maxillary processes
• Disruption of medial canthal lig = traumatic telecanthus (eyes deviate)

Question 11

Fractures of mandible -

Main Points

Answer 11

• Condyler neck = weakest – most common fracture location

– mental nerve paresis
- “guardsman fracture”: blow to chin can cause fracture of maxilla (indirect fracture

Question 12

Soft tissue injuries:

Answer 12

Facial lacerations: have excellent blood supply + heal well. Sutured asap (absorbable sutures) broad spec Ab given

Skin loss: bite injuries – nose + ear. Small tissue losses = can be sutured closed. Large tissue losses = reconstruction with grafts

Facial nerve injury: lateral face wound can damage facial nerve

a. Primary repair should be attempted – several nerve endings approximated using operating microscope

Parotid duct: lacerations in same vicinity as those with facial nerve can transect parotid duct

Treatment of Parotid duct injury
Cannula placed in parotid gl from within mouth .

The proximal duct is then passed over the cannula so approximation of the severed portion of the duct can occur.

Cannula left in position for several days to prevent post-anastomic stricture

Lacrimal apparatus: tissues are grossly edematous
- Epiphora (overflow of tears) = complication