Facial fractures

Question 1

A 40 year old man has been assaulted by another person on his face with a fist. On exam he has bruising over his left orbital region and has ongoing nose bleeding which is mild. How will you assess this patient?

Answer 1

Impression
Assault; concerned about facial fractures and other serious head/neck injuries

DDx
- Head: Facial bone fractures, orbital floor (blow-out) and EOM impingement, mandible/zygoma/TMJ disruption
- C-spine: Fracture
- Nasal septum haematoma
- Eye trauma: dislocated lens, retinal tear/detachment

Goals
- Take trauma approach with primary survey, place in C-Spine collar
- Rule out REDS and facilitate timely definitive management for any facial injuries

Question 2

Facial fractures - Assessment

Answer 2

Assessment
- Conduct A to E assessment, call for senior assistance

A - patent, maintaining, blood in airway +/- suction, avoid NP airway in case of base of skull fractures/cribriform plate injuries, address any ongoing epistaxis (pinch alae, lean forwards, etc). advise patient to NOT blow nose as could orbital compartment syndrome with secondary air reflux
B - RR/SP02 monitoring. Supplemental as required
C - BP/HR/ECG monitoring. IVC and initial bloods (mainly pre-operative in case of theatres),
D - GCS. PEARL. assess for evidence of base of skull fractures (battles sign, raccoon eyes, etc).
o send for urgent non-con CTB in setting of ?intracranial lesion
o assess for eye injuries: rock hard globe, RAPD, proptosis, reduced visual acuity
o call for ophthal involvement if necessary
E - temp, look in nose for septal haematoma + origin of bleeding
o Trismus/misaligned jaw
o depressed fractures

Question 3

Facial fractures - History

Answer 3

History
MIST AMPLE
- MOI, timing,
- Associated sx: blurred vision, painful EO movements, diplopia, numbness, LOC, lucid interval (extradural),

Question 4

Facial fractures - Examination

Answer 4

Examination
- Vitals
- General appearance: ?coning
- Assessment
o palpate facial bones; orbital rim, zygoma, mandible, maxilla, etc.
o assess sensation, specifically across infra-orbital nerve distribution which is likely implicated
o signs of base of skull fracture: raccoon eyes, battles sign, haemotympanum, CSF rhino/otorrhoea, etc
- Eye exam: Assess for gross deformity, check for R Reflex and evidence of ret det via indirect ophthalmoscopy or slit lamp if tolerated.

Question 5

Facial fractures - Investigations

Answer 5

Investigations
Diagnostic
- HR CT Brain + facial bones +/- orbital
- Eye ultrasound: looking for ret det, lens dislocation, retrobulbar HB, etc

• Pre-op bloods

Question 6

Facial fractures - management

Answer 6

Management
Disposition
- urgent ophthal referral if suggestion of ocular injury/ orbital blow-out
- MaxFacs +/- neurosurg referral depending on assessment findings

Definitive
- sinus precautions (sneeze open mouth, no nose blowing, nil air travel/head submersion)
- ophthal review
- surgical ORIF if entrapment of EOM, if no entrapment then non-urgent ORIF

Supportive
- NBM for pre-op
- Empirical ABx if open fracture (as per eTG)
- analgesia + antiemetics as necessary
- cold therapy over wounds for swelling
- sleep with head elevated