Facial Injuries

Introduction

Facial injuries are a high-yield topic for the MCCQE1, often appearing in the context of emergency medicine, trauma (ATLS), and plastic surgery. As a Medical Expert under the CanMEDS framework, a Canadian physician must be able to assess, stabilize, and triage facial trauma effectively.

In Canada, common etiologies include motor vehicle collisions (MVCs), interpersonal violence, and sports-related injuries (particularly hockey and winter sports). Understanding the anatomy, potential for airway compromise, and long-term functional/cosmetic implications is crucial for MCCQE1 preparation.

CanMEDS Perspective

Health Advocate: Recognize the association between facial trauma and intimate partner violence or elder abuse. Always screen appropriately in the history.

Initial Assessment and Management

The primary concern in any facial trauma is the Airway. Facial injuries can lead to rapid airway obstruction due to edema, blood, loose teeth, or posterior displacement of the tongue (in mandibular fractures).

Step 1: Airway and C-Spine Control

Assess airway patency. Look for stridor, hoarseness, or gurgling.

Chin lift/Jaw thrust: Use with caution if C-spine injury is suspected.
Intubation: Early intubation is indicated if there is significant edema, expanding hematoma, or GCS < 8.
C-Spine: Assume C-spine injury until proven otherwise in significant facial trauma.

Step 2: Breathing and Ventilation

Ensure adequate oxygenation. Facial trauma is often associated with chest trauma.

Step 3: Circulation (Hemorrhage Control)

The face is highly vascular. Significant bleeding can occur from the internal maxillary artery.

Control: Direct pressure is usually effective.
Packing: Anterior/posterior nasal packing for epistaxis.
Foley Catheter: Occasionally used for tamponade in penetrating wounds.

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CRITICAL ALERT: Never insert a nasogastric tube or perform nasotracheal intubation if a cribriform plate fracture (midface trauma, CSF rhinorrhea) is suspected. It may enter the intracranial cavity. Use an orogastric tube instead.

Clinical Anatomy and Classification

Understanding the structural buttresses of the face is key to diagnosing fractures.

Le Fort Fractures (Midface)

Le Fort fractures involve the separation of all or a portion of the midface from the skull base.

Le Fort I

Horizontal Fracture (Floating Palate)
Separates the teeth/palate from the maxilla. Fracture line runs above the teeth/palate level.

Mandibular Fractures

The mandible is a ring structure; therefore, fractures often occur in two places (like a pretzel).

Common Sites: Condyle, Angle, Body, Symphysis.
Signs: Malocclusion, trismus, sublingual hematoma.

Zygomaticomaxillary Complex (ZMC) Fractures

Often called a “Tripod” or “Tetrapod” fracture. Result from a direct blow to the cheekbone (e.g., hockey puck, punch).

Components: Zygomatic arch, lateral orbital rim, inferior orbital rim, anterior and lateral maxillary sinus walls.
Signs: Flattened cheek, trismus (impingement on temporalis muscle), diplopia.

Orbital Blowout Fractures

Caused by a direct blow to the globe, transmitting force to the orbital floor (weakest point).

Key Findings: Enophthalmos, restricted upward gaze (entrapment of inferior rectus muscle), infraorbital nerve anesthesia (numbness of cheek/upper lip).

History and Physical Examination

History

Mechanism: High velocity (MVC) vs. Low velocity (fist).
Visual changes: Diplopia, blurry vision.
Occlusion: “Do your teeth fit together normally?”
Numbness: Distribution of CN V (trigeminal).

Physical Exam Checklist

Use this task list during your clinical skills practice or OSCE preparation:

Inspection: Asymmetry, ecchymosis (Battle sign, Raccoon eyes), CSF rhinorrhea/otorrhea.
Palpation: Step-offs along orbital rims, zygomatic arch, and nasal bridge.
Eyes: Visual acuity (Vital!), extraocular movements (rule out entrapment), pupillary reaction (APD).
Nose: Speculum exam to rule out Septal Hematoma.
Ears: Hemotympanum (basilar skull fracture).
Mouth: Malocclusion, loose teeth, sublingual hematoma (pathognomonic for mandibular fracture).
Neuro: Sensation V1, V2, V3; Motor VII (facial nerve function).

MCCQE1 High-Yield: Septal Hematoma

You must identify and drain a nasal septal hematoma immediately.

Pathophysiology: Blood collects between the cartilage and mucoperichondrium, stripping blood supply.

Complication: Septal necrosis leading to a “Saddle Nose Deformity” or septal abscess/cavernous sinus thrombosis.

Diagnostic Investigations

Imaging Guidelines

Modality	Indication	Notes
CT Face (Non-contrast)	Gold standard for facial trauma	Specifically coronal and axial cuts. Essential for midface, orbital, and complex mandibular fractures.
Panorex (OPG)	Mandibular fractures	Excellent for viewing the entire mandible, condyles, and dental roots.
Plain X-rays	Limited utility	Generally replaced by CT. Nasal bone X-rays are often unnecessary as management is clinical (Choosing Wisely).
CT Head	Associated LOC or neuro signs	To rule out intracranial hemorrhage.

Medical Abbreviations


CT    : Computed Tomography
GCS   : Glasgow Coma Scale
LOC   : Loss of Consciousness
MVC   : Motor Vehicle Collision
OPG   : Orthopantomogram (Panorex)
CSF   : Cerebrospinal Fluid
APD   : Afferent Pupillary Defect
CN    : Cranial Nerve

Management Principles

General Measures

Tetanus Prophylaxis: Assess immunization status (Tdap/Td).
Antibiotics:
- Controversial: Not routine for simple lacerations.
- Indicated: Bite wounds (polymicrobial), fractures communicating with sinuses/oral cavity (open fractures), significant contamination.
- Choice: Amoxicillin-Clavulanate or Clindamycin.
Analgesia & Ice: To reduce edema.

Specific Fracture Management

Nasal Fractures:
- Non-displaced: Supportive care.
- Displaced: Closed reduction. Usually performed after 5-7 days to allow swelling to subside, but before 14 days (callus formation).
Mandibular Fractures:
- Often require Open Reduction Internal Fixation (ORIF) or Maxillomandibular Fixation (MMF/wiring shut).
Orbital Blowout:
- Surgical Indications: Significant enophthalmos (>2mm), persistent diplopia (entrapment), large defect (>50% floor).
- Conservative: No nose blowing (prevents orbital emphysema).
ZMC/Le Fort:
- Usually require ORIF with mini-plates and screws.

Soft Tissue Injuries

Lip Lacerations: If crossing the vermilion border, precise alignment of the border is the first step in closure to prevent cosmetic deformity (step-off).
Parotid Duct: Suspect injury in lacerations crossing a line from the tragus to the mid-upper lip. Test by cannulating the duct intra-orally.

Complications

Early: Airway obstruction, hemorrhage, aspiration, infection (meningitis with CSF leak).
Late: Malocclusion, cosmetic deformity, chronic sinusitis, diplopia, nerve paresthesia (infraorbital).
Retrobulbar Hematoma: An Ophthalmologic Emergency.
- Signs: Proptosis, pain, decreased visual acuity, “tense” globe.
- Action: Immediate Lateral Canthotomy. Do not wait for CT.

Canadian Guidelines

Choosing Wisely Canada

Imaging for Nasal Trauma: Do not order X-rays for uncomplicated nasal trauma. A positive X-ray does not change management if the nose is straight and the patient can breathe. Diagnosis and reduction are clinical.
CT Head Rules: Utilize the Canadian CT Head Rule to determine if a CT head is required in minor head injury associated with facial trauma.

Key Points to Remember for MCCQE1

Airway is the priority. Watch for expanding hematomas or loose teeth.
Septal Hematoma: Always look for it; always drain it.
Retrobulbar Hematoma: Clinical diagnosis requiring immediate lateral canthotomy to save vision.
Le Fort Fractures: Know the difference between I (palate), II (maxilla), and III (face).
Mandible: Look for the second fracture; check for malocclusion.
Nasal Fractures: Management is usually delayed (5-7 days) for swelling reduction, unless there is a septal hematoma or open fracture.
Vermilion Border: Must be aligned perfectly in lip lacerations.

Sample Question

Clinical Scenario

A 24-year-old male presents to the emergency department after being struck in the right eye with a fist during a bar fight. He complains of double vision when looking up. On examination, there is periorbital ecchymosis and edema. His visual acuity is 20/25 in both eyes. Extraocular movement testing reveals restriction of the right eye on upward gaze. He also reports numbness over his right cheek and upper lip. The pupil is reactive, and there is no proptosis.

Which one of the following is the most likely diagnosis?

Options

A. Le Fort II fracture
B. Zygomaticomaxillary complex (tripod) fracture
C. Orbital floor blowout fracture
D. Retrobulbar hematoma
E. Naso-orbito-ethmoid fracture

Explanation

The correct answer is:

C. Orbital floor blowout fracture

Explanation: This clinical presentation is classic for an orbital floor blowout fracture.

Mechanism: Direct blunt trauma to the globe increases intraorbital pressure, causing the thin orbital floor to fracture.
Diplopia on upward gaze: Caused by entrapment of the inferior rectus muscle or periorbital tissue within the fracture site.
Infraorbital nerve paresthesia: The infraorbital nerve runs along the floor of the orbit; injury leads to numbness of the cheek and upper lip.

Why other options are incorrect:

A. Le Fort II: Involves the maxilla and nasal bones (pyramidal). While it can cause similar symptoms, the isolated eye findings and specific mechanism (fist to eye) strongly favor a blowout. Le Fort fractures typically involve significant malocclusion and midface mobility.
B. Zygomaticomaxillary complex fracture: Usually involves flattening of the cheek (“tripod” fracture). While it can involve the orbital floor, the primary presentation involves the cheekbone prominence and trismus.
D. Retrobulbar hematoma: This is an emergency characterized by proptosis, severe pain, a “rock hard” eye, and typically an afferent pupillary defect or loss of vision due to optic nerve compression. This patient has no proptosis and good visual acuity.
E. Naso-orbito-ethmoid fracture: Involves the bridge of the nose and ethmoids. Key sign is telecanthus (widening distance between eyes) and CSF rhinorrhea.

References

Advanced Trauma Life Support (ATLS) Student Course Manual. 10th ed. Chicago, IL: American College of Surgeons; 2018.
Choosing Wisely Canada. Emergency Medicine: Five Things Physicians and Patients Should Question. Link
Toronto Notes 2024. Plastic Surgery & Emergency Medicine Sections. Toronto, ON: Toronto Notes for Medical Students, Inc.
Medical Council of Canada. MCCQE Part I Clinical Decision-Making and Multiple-Choice Question Objectives. Link
Borgundvaag B, et al. Management of facial trauma in the emergency department. CMAJ. Canadian Medical Association.