Epidemiology

In 2008 there were more than 40 million injury-related visits to U.S. emergency departments (EDs).¹² Facial injuries accounted for a significant proportion of these visits and resulted from either intentional violence (assaults and attempted suicide) or unintentional trauma (falls, sports injuries, and motor vehicle crashes [MVCs]). The type of injury mechanism can be a good predictor of the extent of facial trauma sustained; for example, MVCs were related to multiple facial fractures, whereas assaults more often involved isolated mandibular fractures.¹³ Although MVCs used to be the most common cause of facial injuries, windshield improvements, increased use of safety belts, and the prevalence of air bags in vehicles are changing the epidemiology of facial trauma. Dual front-impact air bags have been required in all new vehicles since 1999, and safety belts are required for all passengers in the front row in 49 states (all except New Hampshire).¹⁴ Seat belts and air bags significantly reduce the incidence and severity of facial injury in adults.^15–21 Because they effectively prevent ejection, safety belts specifically avert the extensive scalp and facial degloving injuries associated with being ejected through the windshield.

Alcohol use by vehicle occupants decreases safety belt use and independently increases the risk of facial injury in MVCs.²² It also increases the risk of interpersonal violence. In one series, alcohol played a role in 49% of all maxillofacial fractures in patients requiring subspecialty care. Of the fractures related to alcohol use, 78% were a result of interpersonal violence and 13% of MVCs.^23,24 Interpersonal violence is increasingly cited as the cause of facial injury, particularly in inner-city populations.^25–28 Falls, dog bites, some athletic activities, and flying debris are other common causes of facial injuries.

Because of the lack of external protection, facial injuries are common among riders of other motorized vehicles, particularly those who are not wearing helmets with face guards, including all-terrain vehicles (ATVs) and motorcycles. In one series in Alabama, 32% of injured ATV riders had a facial injury, and the presence of a facial injury was associated with increased overall injury severity.²⁹ Among the youngest riders, facial injuries predominate: 31.1% of 0- to 5-year-olds injured while riding an ATV required emergency treatment for a facial injury in 2001 through 2003, although multiple safety and medical groups recommend no ATV use by people younger than age 16 years.³⁰

In motorcyclists, there is a significant association between facial injury and brain injury.³¹ Helmets reduce the risk of brain injury but may not protect against facial trauma unless they include a face guard.³²

Unfortunately, a separate group of the injured must now be considered: combat veterans. A review of injuries sustained in battle by combatants in Operation Iraqi Freedom and Operation Enduring Freedom and treated by U.S. military medical facilities for at least 72 hours revealed that 19% of patients sustained injuries to the face, ears, or eyes. Of all these injuries, 19% were caused by gunshots, 79% by explosive devices, and 2% by MVCs.³³

In children younger than age 17 years, sports injuries account for 21% of facial and 29% of nasal fractures requiring specialist evaluation.34,35 Baseball and football helmets with face guards are successful at preventing childhood facial injuries, and their use should be encouraged by emergency physicians.³⁶ Children younger than age 6 years seem to be at significant risk for severe facial injuries from bites from the family dog.³⁷ Interactions between pet dogs and young children require careful supervision.

Facial injuries are a common acute presentation for victims of domestic violence. In one series, 81% of domestic violence victims had maxillofacial injuries on presentation, 30% of them with facial fractures. The location of the injury was consistent with the predominance of fisted assaults; left-sided injuries predominated.38,39 Women visiting the ED with facial injuries should be interviewed privately to allow an opportunity for disclosure and intervention for domestic violence.

Pediatric facial injury accounts for less than 10% of all facial trauma, and the face is the most common area of trauma in children suspected of being victims of abuse.⁴⁰ However, the epidemiology of facial trauma among children reflects their physical development and behavioral patterns: toddlers learning to walk have a “falling zone” of trauma to the perioral region, nose, and forehead. Younger children are significantly more likely to have minor soft tissue injuries and to have been the recipient of a dog bite. Severe facial injuries in all pediatric age groups are more likely to be the result of an MVC or assault.⁴¹ Care should be taken by the emergency physician to correlate the child’s age and behavioral ability with the history of the injury and the physical findings. In particular, injuries to the lips or frenulum in a nonambulatory infant suggest “bottle jamming,” and bruises to the cheeks or neck are less common in falls. Although dental fractures in young children are relatively common, facial fractures before age 5 years are rare. If there is any question, the appropriate local authorities are contacted.

Even in high-energy MVCs, appropriate use of child safety restraints protects against many facial injuries. The law in all 50 states requires the use of such restraints for children younger than age 4 years, and currently 48 states require booster seats until at least age 7 years and many beyond that age.¹⁴ Children younger than age 15 years involved in frontal crashes or exposed to a deploying frontal impact air bag had a higher incidence of minor facial and chest injuries and severe upper extremity injuries, mostly related to being struck by the bag.⁴³ As part of preventing facial trauma, parents should be encouraged to ensure that children younger than 12 years ride in the rear seat of the vehicle and that all are properly restrained.

Anatomy

The face is a complex hollow space encapsulated by a bony structure overlaid with muscle and skin. It includes several special sensory organs: the eyes, ears, nose, and mouth.

Pathophysiology

The basic mechanism of all injury is the transfer of energy, most often kinetic, to the structures of the body. When the energy overcomes the tolerance of the underlying tissue, injury results. Trauma traditionally has been classified as blunt or penetrating, but in many cases the effect is a combination of the two, such as the forehead injury (contusion and complex laceration) resulting from a child’s fall against the sharp corner of a coffee table. The likelihood of injury is related to the amount of energy transferred and the condition of the underlying tissue. Significant injury may result when an 80-year-old falls from standing to a carpeted floor, but it is more likely to result when the face strikes the steering wheel or dashboard in a high-speed MVC.

The mechanism can be broken down into low-energy events, such as a fall from standing or walking into the corner of a piece of furniture, and high-energy events, such as an MVC. Understanding the mechanism of injury can help predict not only the severity of the facial injury but also the risk of associated cervical or brain injuries.

Traditional teaching has been that the face protects the brain from injury and that patients with facial trauma are less likely to have a significant brain injury. This does not appear to be correct. Instead, recent work suggests a significant increase in risk for brain injury among blunt trauma patients with facial fractures.⁴⁴

The association between cervical injury and facial injury is unclear. The traditional teaching has been that the presence of a facial injury should increase the suspicion of an injury to the cervical spine. However, most of the studies supporting this idea are assessments of the incidence of cervical spine injury in patients with facial injury.⁴⁵ When more sophisticated methods are used to assess any association between the two while correcting for the mechanism of injury, patients with facial injury appear to be less likely to have a significant cord injury, and there is no relationship with bony spinal injury.⁴⁶ Thus in a particular patient, cervical and brain injuries should be considered based on the mechanism of injury and presentation of the patient without allowing the presence or absence of a facial injury to change the level of suspicion.

Penetrating trauma to the face from gunshots, stab wounds, blast debris, or impalement is often obvious and dramatic (Fig. 42-5). The astute emergency physician should search avidly for associated intracranial, spinal, or vascular injuries, which are common in these cases.⁴⁷ Facial penetration from pellets (BBs) or small blast debris or shrapnel may be less obvious, and the emergency physician should be alert to the possibility based on the history and should carefully search for small skin lesions.⁴⁸ Recreational hobbies such as paintball and new law enforcement weapons such as the “flash ball,” which can have substantial kinetic energy, have caused significant facial and upper body trauma.^48a–48b

History

The history can provide information about the mechanism of the patient’s injury. The emergency physician, however, should be alert to limitations of the history in cases in which the patient’s consciousness is altered by head injury or intoxication, there is an issue of secondary gain, the police are involved, or abuse is suspected. Patients with a clear sensorium are able to describe the events leading up to the injury and localize pain; deficits in motor or sensory function; and abnormalities of vision, hearing, taste, or smell. Although the association between facial trauma and brain or cervical spine injury is unclear, these possibilities should be considered, and the patient should be questioned regarding headache, peripheral weakness, numbness, or paresthesias.

Physical Examination

Many facial injuries can be identified by simple inspection. During the primary assessment, attention is initially on the patient’s airway, and inspection of the oropharynx is an essential first step. Airway compromise is often a result of intraoral trauma, and the examiner should note excessive bleeding, drooling, dysphonia, swelling of the tongue or posterior pharynx, and the presence of avulsed teeth. When the patient is stabilized, a secondary survey should include a systematic examination of all facial structures and functions. Bony prominences should be palpated for abnormal motion, bony crepitus, tenderness, or step-off. Tenderness and massive swelling associated with facial trauma may preclude reliable palpation of a fracture. Consequently, areas of significant swelling should be imaged radiographically. Assessment of bony integrity includes testing for possible Le Fort fracture. The upper incisors are grasped and pulled anteriorly. Movement of the upper alveolar ridge (type I), midface (type II), or entire face (type III) indicates a fracture. Wounds may need to be palpated for underlying bony injury or foreign objects; anesthesia may be required for a thorough examination within the wound. Complex lacerations involving the cartilage of the nose or ear, eyelids, lacrimal apparatus, eyebrows, or vermilion border of the lips should be identified because their repair requires special techniques.

Imaging

The choice of imaging for facial fractures depends on the patient’s stability, the patient’s ability to cooperate, and the availability of various options. The two main options are plain x-ray examination and computed tomography (CT). Fractures are better visualized with CT than with magnetic resonance imaging, so magnetic resonance imaging is not an optimal imaging choice. In patients who cannot cooperate for plain x-ray examination or in whom a fracture or penetrating injury is obvious from the physical examination, CT is the imaging modality of choice.⁵¹ For a complete evaluation, CT scans of the face should include coronal and sagittal reconstructions. Interpreting facial CT scans is an art that requires attention to bones, sinuses, orbital contents, and soft tissue and is best handled by radiologists.

With the increasing use of CT in emergency medicine and the advent of telemedicine, most 24-hour EDs have access to CT scanners for facial injuries. CT is now the first choice for all patients in whom a midface fracture is suspected. However, when no scanner is available and in patients with low to moderate pretest probability of a midface or maxillary fracture and who are stable and able to cooperate, the current recommendation is for a single screening view (Water’s or occipitomental view), followed by CT if the film is positive for a fracture or air-fluid level in any sinus.52–54

The U shape of the mandible and the presence of nearby bony structures make isolating the mandible on flat film impossible. Simple radiographs of the mandible are less sensitive than panorex radiographs and particularly tend to miss fractures of the condyle (Fig. 42-6). If available, panorex imaging is indicated for isolated mandibular fractures, dental fractures, or fractures of the alveolar ridge. In children, if fracture of the condyle is suspected, coronal CT is more sensitive and specific than panorex studies.⁵⁵ Although the traditional teaching has been that the mandible’s shape results in two fractures if it is fractured at all (Fig. 42-7), a case series using CT evaluation found that 42% of mandibular fractures were unifocal.⁵⁶

For patients with complex fractures, new imaging techniques may help improve surgical planning and esthetic outcomes. In displaced orbital fractures, use of CT data to measure orbital volumes has shown that after repair an orbital volume greater than 4% larger than on the unfractured side is associated with visible postoperative enophthalmos.⁵⁷ This method seems to be useful in predicting which patients might benefit from operative repair.⁵⁸ In conjunction with more standard two-dimensional facial CT scans, three-dimensional CT scans seem to improve the diagnosis and aid preoperative planning for patients with complex fractures of the midface (Fig. 42-8B).^59–62

Patients with tenderness and swelling isolated to the bony bridge of the nose who do not have a septal hematoma, can breathe through each naris, and have a straight nose do not require nasal bone radiographs in the ED because imaging results would not alter treatment. If these criteria are not met, early reduction or referral for surgical intervention may be indicated, and plain films (for truly isolated injuries) or CT scanning (if concern for other injuries exists) is indicated. Plain x-ray examination may also be performed in the setting of legal concerns. If there is concern for a foreign body in a superficial wound, two standard x-ray views (Water’s and Caldwell’s or occipitofrontal view) are indicated to triangulate the position of the observed foreign material.

Patients with suspected ocular injuries may benefit from a bedside ultrasound as a noninvasive and economical diagnostic tool, particularly if there is a need for urgent operative management of other injuries and no time for a dedicated facial CT. The different acoustic impedances of the orbit’s anatomic structures make the modality operator friendly, and an ultrasound of the eye can readily detect vitreous hemorrhage, retinal detachment, and globe rupture (Figs. 42-9 and 42-10). The operator should position the transducer in a transverse orientation, scanning in a cephalad-to-caudad direction, making sure to scan the entire anatomy of the eye, and using special care to minimize the pressure exerted over the eye, especially when evaluating for specific ocular emergencies. Prior findings have suggested that high-resolution ultrasound has at least a 94% correlation with axial and coronal CT imaging in the detection of orbital fractures and emphysema.^63,64