Facial Trauma Assessment

Adapted from Dr. Calabrese's October 12th Grand Rounds presentation.

Evaluation of every facial trauma patient should include a complete facial assessment

• Do you have numbness in your face? 
  • Lower lip/chin (mental n)
  • Cheek, upper lip, nose
  • Lower lid, cheek
• What part of your face hurts?
• Do your teeth fit normally? 
  • Alveolar ridge fractures vs. mandibular fractures
• Does it hurt to open your mouth?
  • Zygomatic or high mandibular fractures
• Does your neck hurt?
• Complete evaluation of pupils and extra-ocular movements. 

Evaluation of the patient with Facial Trauma

Patients presenting with facial trauma have several immediate concerns

• Evaluation of the airway
• Bleeding into the airway
• Unstable Facial fractures
• Brain and cervical injuries

Agitation can be due to pain, intoxication, or air hunger/airway compromise. It is important to not only recognize agitation but attempt to identify the cause. 

Your secondary survey must evaluate for skull and facial fractures, neurological injuries, and insidious airway injuries. 

• Battle Sign or Raccoon Eyes
• Unstable midface (Lefort Fractures)
• Extraoccular muscles and orbital trauma
• Mandibular fractures/dental alignment
• Crepitus
• Injuries hidden by a cervical collar

Orbital Injury & Entrapment

Evaluation of orbital fractures is important to identify entrapment of the extra-ocular muscles. Patients who have extra-ocular muscles require emergent ophthalmology consults if they have afferent pupilary defects or increased pressure, concerning for retrobulbar hematomas or nerve impact. A very subtle orbital floor fracture may present as a slight difference in the level of the pupils. 

Lateral Canthotomy Indications

Suspected acute orbital compartment syndrome (OCS), plus one or more of the following:

• Decreased visual acuity
• IOP >40 or marked difference in globe compressibility by palpation
• Proptosis

​Secondary indications (subjective and nonspecific) - if only secondary indications are present, get emergent ophthalmology consult prior to performing canthotomy.

• Afferent pupillary defect
• Cherry red macula
• Ophthalmoplegia
• Nerve head pallor
• Significant eye pain

Nasal Injury

Evaluate all your facial trauma patients for septal hematomas, nasal fractures and dislocations, and telecanthis (flattening of the nasal bridge). Telecanthis can indicate a higher potential for CSF leakage, and these patients will require further monitoring. 

​Septal Hematomas can lead to; 

• Infection
• Erosion or necrosis of the septum causing Saddle Nose deformity
• Septal perforation

Mandibular Injury

Evaluate not only the external mandible, but also the oral floor to evaluate for hematoma or expanding mass. Mandibular fractures can lead to airway compromise by deformation of the airway or tongue displacement. 

Lefort Fractures

Patients with an initial evaluation concerning for a 'flattened' appearance to the face or significant trauma should have a higher suspicion of maxillary fractures leading to one of three Lefort fractures.