Chapter 31 Management of Facial Injuries

Wilderness medicine is defined in terms of the amount of time that an individual is remote from definitive hospital-based care. This definition allows for the inclusion of disaster medicine, military or tactical medicine, rural emergency medical services systems, and traditional wilderness medicine. These fields have in common their resource-constrained environments, necessity for expanded prehospital patient care, and delayed access to definitive care. These conditions require integrating evacuation and rescue training, evaluating environmental threats, and understanding and ability to make use of resources during disasters. A more expansive definition of wilderness medicine also includes the type of injury, setting in which the injury occurred, and, more specifically, how a particular injury relates to human interaction with the environment.⁴¹ In all of these environments and situations, facial injuries occur and require urgent initial management to diminish morbidity, mortality, and the disruption of recreational activities.

The Joint Theater Trauma Registry is responsible for collecting and organizing medical treatment data about patients from combat operations who are treated at U.S. medical facilities. Although the head, face, and neck account for only 12% of the body surface area, approximately 40% of all injuries that are sustained during military conflicts are to this region. This proportion is higher than previous military conflicts, and it is most likely the result of improved body armor and the relative lack of protective devices for the head and face.^32,^38,⁵⁰ Soldiers are at high risk for sustaining oral and facial trauma during training and assaults.⁵² Traumatic facial injuries account for significant morbidity and mortality among U.S. armed forces, so improved functional protection for the vulnerable facial region must be developed.

Experience and data gathered during military conflict have provided tremendous value with regard to further education of medical providers about emergency care of facial trauma. Research published by the military has been instrumental to advancing trauma care principles and guidelines used to manage trauma in both civilian and military populations.

In addition to military-related injuries, sports-related accidents are responsible for a significant number of orofacial injuries. Skiing, bicycling, soccer, and mountain biking account for more than 60% of sports-related accidents. Traumatic injuries as a result of falls, collisions, and self-inflicted injuries result in facial bone fractures, dentoalveolar trauma, and soft-tissue damage. The injury pattern depends on the sporting activity, with high-speed and high-impact sports causing more fractures and low-speed and low-impact sports producing more dental injuries.⁴⁸

A growing number of people are participating in a wide variety of outdoor recreational activities that take them farther away from definitive medical services.^14,⁴⁶ Wilderness recreation and adventure activities create many situations that place individuals at risk for facial traumatic injury. The National Outdoor Leadership School (NOLS) collects and publishes data about injuries, illnesses, near-miss incidents, nonmedical incidents, and evacuation profiles among their participants. Per recent unpublished NOLS data, facial trauma accounted for 4% of all reported injury incidents over a period of 25 years from 1984 to 2009; the majority of these were soft-tissue injuries. The NOLS commitment to risk management and developing strategies aimed at preventing serious injuries and fatalities while meeting educational objectives has provided a better understanding of injury patterns.²⁶

History and Examination

Before evaluating and treating a patient with injuries in the wilderness, the setting and situation must be evaluated to determine the safety of the environment. Evaluating a patient with facial trauma proceeds as it does with any other medical condition. In emergency situations, obtaining the chief complaint and history of the present illness takes place simultaneously with the performance of the primary survey. The primary survey evaluates and treats inadequacies in the areas of airway, breathing, and circulation. The patient’s baseline mental status is assessed and any neurologic disabilities are identified.

Examine the mouth and pharynx for foreign bodies such as blood clots, tooth or bone fragments, and dentures. If the airway is obstructed, perform a chin lift or a jaw thrust, or insert an oropharyngeal airway to hold the tongue forward. If there is a potential cervical spine fracture, keep the head and neck in a neutral position without hyperextension. Position the patient to maintain the airway and to facilitate respiratory exchange; in many instances, this will be the prone position. Raise the head above the heart to decrease bleeding and swelling, or position the victim seated with the head forward so that blood drains from the mouth or nose. If these measures fail, perform endotracheal intubation or cricothyrotomy. Do not leave the patient unattended, especially in a supine position.

After the airway is secured and the victim is stabilized, perform a secondary survey to obtain an abbreviated history of the present injury or illness and to extract pertinent information, such as allergies, medications, medical history, the presence of complicating medical factors or chronic illnesses, last oral intake, and events leading up to the injury. If the victim has sustained significant head or facial trauma, determine if he or she experienced a loss of consciousness or has symptoms of nausea, vomiting, visual disturbances, or headache. Assess the patient’s pain, and ask about its character, onset, location, radiation, and duration. Determine if anything exacerbates or relieves the pain.

The focus of the examination depends somewhat on the provider’s clinical impression. However, in all cases, a systematic approach to examination in oral and maxillofacial emergencies allows for efficient collection of relevant information. Start the examination with a general appraisal that includes the vital signs. Clean the face, mouth, head, and neck of blood and debris; this unmasks soft-tissue injuries and facilitates diagnosis. Next, observe the head, neck, and face, and note any asymmetry. Palpate all facial bones, temporomandibular joints, muscles, and areas of suspected injury for tenderness, crepitus, swelling, instability, dislocation, fracture, and foreign bodies. Bimanually palpate the lips, the cheeks, and the floor of the mouth. Observe the patient slowly opening the mouth, and examine for range of motion and any deviation with opening. Evaluate facial soft-tissue swelling for hematoma formation, especially in areas that are associated with underlying cartilage, such as the ear and nose.

Perform an intraoral examination of the lips, cheeks, mouth, tongue, hard palate, soft palate, and pharynx. Examine facial lacerations carefully to determine if they penetrate through the skin into the oral cavity or if they contain foreign material. Gently retract the lips with the teeth closed to examine soft tissues and occlusion. Examine dentition for fractures and mobility. Observe the gingiva for bleeding, swelling, trauma, color, firmness, and recession.

Temporomandibular Joint Disorders

Temporomandibular joint (TMJ) dislocation is more commonly referred to as mandibular dislocation. Dislocation of the mandibular condyles causes an inability to close the mouth and may result from external trauma or, more frequently, from mandible hyperextension. This may occur in any environment while yawning, taking a large bite when eating, vomiting, laughing, or performing oral sex. This condition may be bilateral or, less often, unilateral, and it frequently recurs.⁸

Although posterior, lateral, and superior dislocations occur, anterior TMJ dislocation is most common, and it occurs when the mandibular condylar heads and their respective cartilaginous discs move anteriorly along the articular eminence out of the glenoid fossa and become locked in the anterior–superior aspect of the articular eminence of the temporal bone. Dislocation is complicated by involuntary spasms of the muscles of mastication, including the masseter, temporalis, and medial pterygoid, thereby making it extremely difficult for the condyles to return to their normal position during reduction.^1,^8,³⁷

Diagnosis of TMJ dislocation is not difficult, but, without the benefit of a medical history can be confused with an acute dystonic reaction. Patients present with difficulty speaking, acute jaw pain anterior to the ear, malocclusion, and inability to open or close the mouth. They may be extremely uncomfortable and anxious. Patients present with an open mouth and a prominent-appearing lower jaw. If the dislocation is unilateral, the chin will appear to deviate to the side opposite the dislocation. More frequently, dislocation is bilateral without chin deviation. Clinically, the patient may have a palpably absent condyle within the glenoid fossa and visible periauricular depression.^8,^27,²⁸

Ideally, with traumatic dislocation, radiographs are performed to eliminate a condylar fracture. In the wilderness environment, radiography is impossible, and fracture exclusion must be done on the basis of clinical examination alone.

In the wilderness, a variety of methods may be attempted to reduce anterior mandibular dislocations without procedural sedation or local anesthesia. The goal of the reduction process is to relocate the mandibular condyle to the glenoid fossa and out of its current location anterior to the articular eminence of the temporal bone. This requires relaxing the muscles of mastication, and is accompanied by properly positioning the provider and patient so that direct pressure can be placed on the mandible during relocation.⁸ Multiple reduction techniques are used that do not require conscious sedation or local anesthesia (Figure 31-1).

FIGURE 31-1 Reduction of temporomandibular joint dislocation. The temporomandibular joint is shown in both normal and dislocated positions. 1, Closed position, with the mandibular condyle resting in the mandibular fossa behind the articular eminence. 2, In the maximally open position, the condyle is just under and slightly behind the eminence. 3, In the dislocated position, the condyle moves forward and upward slightly above the eminence; muscle spasm then occurs. 4, To reduce dislocation, place the thumbs intraorally and lateral to the lower molars, and apply downward pressure to the lower molar ridge area near the jaw angle in a downward and backward direction. 5, When the condyle has cleared the articular eminence, muscle contraction will return the jaw to a normal closed position. The patient sits on a low chair with the back straight. Face the patient, wrap the thumbs with gauze for protection, place them in the mouth on the back molars, and then push down and back. A rocking motion may help.

(From Amsterdam JT: Oral medicine. In Marx JA, Hockberger RS, Walls RM, editors: Rosen’s emergency medicine: Concepts and clinical practices, ed 6, Philadelphia, 2006, Mosby, p 1041.)

To perform the classic reduction technique, seat the patient lower than you and stabilize his or her head. Stand facing the seated patient, and ask the patient to open his or her mouth widely against resistance; this reduces muscle tone of the elevator muscles through reciprocal inhibition and allows for concurrent manual reduction. Simultaneously exert maximal downward reduction force with the use of gloved thumbs on the patient’s lower molars or mandibular ridge while exerting steady and constant downward pressure by moving the mandible down, then posteriorly, and then up with the remainder of the fingers and hand around the jaw and chin, levering upward. The downward pressure clears the condyle of the articular eminence, whereas the posterior pressure repositions the condyle within the glenoid fossa. This technique may be difficult if muscle spasm is severe ^8,²⁸ (Figure 31-2).

FIGURE 31-2 Classic technique for the reduction of anterior mandibular dislocation.

For the recumbent approach, lay the patient on his or her back, and, standing either behind or in front of the patient, apply caudal pressure on the mandibular ridge ⁸ (Figure 31-3).

FIGURE 31-3 Recumbent approach for the reduction of anterior mandibular dislocation.

For the posterior approach, seat the patient either on the floor or a chair, and stand behind and above the patient. Place the thumbs on the retromolar gum posterior to the patient’s last molar along the mandibular ramus, and exert downward pressure on the mandible ⁸ (Figure 31-4).

FIGURE 31-4 Posterior approach for reduction of anterior mandibular dislocation.

For the ipsilateral approach, use a sequential combination of intraoral and extraoral manipulation. Focus on one side of the jaw at a time. Stand on the side of the patient, and, while stabilizing the patient’s head with one hand, use the thumb of the other hand to exert external downward pressure on the displaced mandibular condyle, which is located anterior and inferior to the zygomatic arch. If this is unsuccessful, exert downward pressure intraorally on the ipsilateral lower molar teeth or the mandibular ridge. If this is still unsuccessful, a combination of intraoral downward pressure on the posterior molars along with external downward pressure on the mandibular condyle may be successful ^8,⁴³ (Figure 31-5).

FIGURE 31-5 Ipsilateral extraoral approach for reduction of anterior mandibular dislocation.

For an alternative manual method, place your fingers over the periauricular-dislocated condyle, and then gently massage the musculature posteriorly and inferiorly to induce relaxation of the muscles and reduction of the condyle into the glenoid fossa.^8,²¹

For the wrist pivot method, face the seated patient while standing, and place your thumbs on the apex of the patient’s chin while wrapping the remainder of the fingers laterally over the mandible onto the inferior molars of the patient. With this method, push upward with the thumbs on the patient’s chin while at the same time pushing downward on the body of the mandible with the remaining fingers in a pivoting action. Flex your wrists, and move in the direction of ulnar deviation. The pivoting action uses the angle of the jaw as a fulcrum, and this results in rotation of the mandibular condyles back into the glenoid fossa. To prevent injury to the mandible, this technique must be applied to both sides of the jaw concurrently ^8,²⁷ (Figure 31-6).

FIGURE 31-6 Wrist pivot method for reduction of anterior mandibular dislocation.

For the gag reflex method, elicit a patient’s gag reflex by stimulating the soft palate. This results in mastication muscle relaxation and the descent of the mandible caudally as part of the reflex. During the gag reflex, the jaw muscles relax, thereby causing transient descent of the mandible inferiorly and forcing the condyle to relocate back into the glenoid fossa.^2,⁸ Alternatively, have the patient open his or her mouth widely or against resistance to cause reciprocal relaxation of the elevator muscles to allow for simultaneous manual reduction.

With the nerve block method, the peripheral masseteric nerve is anesthetized where it has passed through the mandibular notch and before it penetrates the masseter. The deep temporal nerve may be anesthetized by locating the anterior temporalis muscle within a depression just above the zygomatic bone. The greater wing of the sphenoid bone is located deep below this portion of the muscle. The anesthetic needle is directed into this area until the needle hits the sphenoid bone and the anesthetic is deposited. These blocks result in reduction of pain and muscle spasm, thereby allowing manual reduction. Administration of a local anesthetic agent around the TMJ capsule may diminish joint pain, but it will not diminish muscular pain or spasm ⁵¹ (Figure 31-7).

FIGURE 31-7 Masseteric nerve block for reduction of anterior mandibular dislocation. The index finger locates the zygomatic arch and moves inferiorly until it reaches the mandibular notch at a point halfway between the thumb and the middle finger. The needle is introduced posterior to the index finger to hit the neck of the condyle.

Complications of the various reduction techniques include intraoral trauma from significant downward pressure on the teeth and gums, fractures, joint cartilaginous injuries, and torn ligaments and muscles. More frequently, the provider’s fingers are injured during the intraoral relocation techniques when the jaw snaps shut after successful reduction and relocation. Using gloves, gauze, bite blocks, and plastic finger splints as well as placing the thumbs on the mandibular ridge rather than the teeth or gums during the reduction process can prevent this.⁸

After reduction, advise patients to apply ice or cool compresses to the TMJ, to avoid hyperextending the mandible, to take nonsteroidal antiinflammatory agents such as ibuprofen, and to maintain a soft diet for a week. Wrap a bandage around the head and jaw to prevent mandible hyperextension and to limit jaw movement.^8,¹⁶

Internal Derangements of the Temporomandibular Joint

Between the movable mandibular condyloid process and the articular eminence of the temporal bone, there is a cartilaginous disc that is interposed between these articulating components. The disc stabilizes the joint and allows for rotational movements. The intra-articular cartilaginous disc may displace anteriorly, which results in joint dysfunction and abnormal joint sounds such as clicking or popping. When closing the mouth, if the cartilaginous disc of the TMJ displaces anteriorly relative to the mandibular condyle with reduction to its normal position when the mouth opens, clicking of the joint may occur. This may manifest itself as a pop, which is the noise that is heard when the condyle moves under the anteriorly displaced disc; this may or may not be associated with joint pain and dysfunction ²⁵ (Figure 31-8).

FIGURE 31-8 A, The normal temporomandibular joint with cartilaginous disc. B, In a closed lock, the ligaments have stretched, and the disc is trapped anterior to the condyle.

However, if the cartilaginous disc is displaced but does not reduce and return to its normal position on mouth opening, then the patient may experience occlusive instability associated with jaw locking. There are two types of lockjaw. With closed lock, the mandibular condyle is unable to slide under the anteriorly displaced disc. With open lock, the mandibular condyle is unable to slide back over the disc into its normal position.³⁶ Clinically, there is joint tenderness on palpation, and the chin may be deviated toward the affected side on attempted mouth opening. Functionally, the disc is trapped anterior to the mandibular condyle, and the ligaments are stretched and become inflamed. This can occur spontaneously while eating or talking, but it may be present on awakening from sleep, and it may be associated with mandibular trauma.

The provider can attempt to instruct the patient to reduce a closed lock. To do this, the patient should close the mouth until the teeth almost touch, move the mandible laterally as far as possible to the affected side, and finally swing the mouth fully open.³⁶ If these maneuvers fail, consider manual reduction using techniques that were described for TMJ reduction. Myospasm of the muscles of mastication may cause similar restriction in mandibular function, but typically the affected muscles are firm and extremely tender; alternatively, with closed lock, the muscles are usually normal.

Epistaxis

Although most cases of nosebleed are trivial, some become life threatening, because aspiration can lead to respiratory compromise, and extensive blood loss can result in hemodynamic collapse. Therefore, the condition should never be neglected. It is more common among the young and elderly. Most causes are traumatic and occur in winter.³⁷ Spontaneous epistaxis is more common in environments that are cold, dry, dusty, or smoke filled. Anterior nosebleeds may be managed definitively in the wilderness, but posterior bleeds require immediate evacuation as a result of continued hemorrhage and the potential for airway compromise.²⁹

The nasal mucosa is highly vascular, with superficial exposed blood vessels that arise from the terminal branches of both the internal and external carotid arteries that serve to warm and humidify inspired air. Epistaxis is normally classified into anterior or posterior, depending on the anatomic location of the bleed. A particularly rich collection of vessels and a common site of anterior nosebleed is Kiesselbach’s plexus on the lower anterior part of the nasal septum (i.e., Little’s area). This area accounts for 90% of epistaxis. Posterior bleeding originates primarily from a branch of the sphenopalatine artery called the posterior nasal artery, which forms part of Woodruff’s plexus ^19,⁴⁹ (Figure 31-9).

FIGURE 31-9 A, Vascular supply to the septum. The most common site of anterior epistaxis is within the area that is labeled Kiesselbach’s plexus. B, Vascular supply to the lateral wall. The most common site of posterior epistaxis is the sphenopalatine artery as it emerges posterior to the middle turbinate.

(From Maceri DR: Epistaxis and nasal trauma. In Cummings CW, editor: Otolaryngology: Head and neck surgery, ed 2, St Louis, 1993, Mosby, p 728.)

Initial evaluation requires first determining if the patient’s bleeding is unilateral or bilateral and whether it is coming from an anterior or posterior site. A nosebleed usually occurs on one side of the nasal cavity. However, with profuse bleeding, blood can pass behind the nasal septum and also appear on the unaffected side. Most individuals bleed from an anterior site, which is visualized on intranasal speculum examination, whereas with posterior epistaxis the bleeding point cannot be seen on intranasal examination.

Evaluate and treat a nosebleed by having the patient sit upright with his or her head tipped slightly forward. This maneuver will decrease blood flow through the nasopharynx and allow blood to drip passively out of the nose rather than flow posteriorly into the throat and cause choking, aspiration, and vomiting swallowed blood. Have the patient blow the nose to remove any clots immediately before examination. Warm saline lavage of each nostril may accelerate activation of the clotting cascade and allow for better visualization of the bleeding areas.⁴⁹ Bleeding may resume, but there will be improved access and visibility for the application of a vasoconstrictor or chemical cautery. Ask the patient if he or she has put anything up the nose to stop the bleeding so that it can be removed before additional packing is placed. Examine the nasal cavity with a nasal speculum to determine the site of bleeding. Instruct the patient to pinch the fleshy alae tightly against the cartilaginous septum portion of the nose between the thumb and index finger for at least 10 to 20 minutes. Applying cold compresses to the nose and instructing the patient to suck on ice can improve this.³⁹ Pinching the bony bridge of the nose does not provide direct pressure on the bleeding vessels. Alternatively, hands-free techniques that involve the use of external pressure devices fashioned from taping together two tongue depressors or a commercially available nose clip also work well.¹⁹

If a bleeding point is localized and nose pinching does not stop the bleeding, apply local anesthetics and vasoconstrictors to the nasal mucosa over Little’s area. Anesthetic preparations include topical tetracaine 1%, cocaine 1% to 4%, lidocaine 5%, ephedrine 5%, and aqueous epinephrine 1:1000. Vasoconstrictive nasal sprays include phenylephrine 0.5% (Neo-Synephrine) and oxymetazoline 0.05% (Afrin). Apply anesthetics and vasoconstrictors by drip or spray, on a cotton pledget, or with a cotton-tipped applicator. Objects placed in the nose should have a string attached or include another method of easy removal and they should be aimed posteriorly. Avoid pushing material laterally into the turbinates or superiorly toward the cribriform plate. Leave the vasoconstrictor in place for 10 minutes to 24 hours.²⁹

Epistaxis that is refractory to pressure and topical vasoconstrictors may require chemical cauterization with use of a silver nitrate stick of 75% concentration that reacts to the mucosal lining to produce local chemical damage. After applying a topical anesthetic, apply a cautery stick to the bleeding point with firm pressure for 5 to 10 seconds. Apply the cautery only to one side of the septum, and be careful to not perforate the septum by applying too much pressure.¹³

When there is more vigorous anterior nasal bleeding, nose pinching, topical chemical vasoconstrictors, and cautery may not be effective. In such an instance, inject the anterior bleeding site with 0.5 to 1 mL of lidocaine 0.5%, 1%, or 2% that contains 1:100,000 epinephrine. This has a tamponading effect as well as a vasoconstrictive effect. Alternatively, directly over the bleeding site, insert into the nares a small piece of absorbable or degradable material that does not require removal. Such materials include oxidized regenerated cellulose (Oxycel or Surgicel), purified bovine collagen foam or paste (Gelfoam), microfibrillar collagen (Avitene), porcine gelatin (Surgiflo), bovine gelatin-human thrombin (FloSeal), QuikClot, recombinant factor VIIa, topical thrombin, hemostatic matrix, nosebleed gauze, and fibrin glue.^19,^33,^34,³⁹ After the bleeding has stopped, instruct the patient to not blow the nose or probe the area for 48 hours. Increase the humidity, warm the inspired air, and moisturize the nasal mucosa with topical gels, lotions, and ointments to help prevent recurrent bleeding.

Treat persistent epistaxis by packing the anterior cavity, posterior cavity, or a combination of both. If the site of bleeding is not controlled by the previous methods, insert a lubricated anterior nasal sponge or tampon. Improvise with gynecologic tampons, sponges, and gauze. Current commercial options include Merocel, Medtronic, Rapid Rhino, ArthroCare, Weimert Epistaxis Packing, and Rhino Rocket ³⁴ (Figure 31-10).