Chapter 56: Craniomaxillofacial Trauma

Causes

• Facial injuries can vary from the most minor laceration to the most severe disruption of the face, as seen in shotgun blasts.

• Often described as blunt or penetrating and by the amount of energy.

• Low impact (so-called “low energy”) injuries are often due to falls and fights.

• Moderate energy injuries are often due to low-velocity vehicular trauma, falls from moderate height, and interpersonal trauma that involves a blunt weapon.

• High-energy injuries are often due to high-speed vehicular trauma and recreational vehicles, industrial accidents, and falls from height.

• Penetrating injuries are often due to gunshots and can vary from small holes and limited damage to areas of destruction and major tissue loss.

• Management depends upon the nature of the injury.

Anatomy

• The face includes an underlying bony skeletal support structure with a very complicated 3D structure.

• The skeleton provides facial shape, which is important for both function and cosmesis.

• The skeleton also provides support and protection for viscera, including the eyes and brain.

• The paranasal sinuses are mucosally lined cavities within the facial skeleton. These may lighten the face/head, and they also serve as a protective “crumple zone” for the nearby viscera.

• The upper and lower jaws contain teeth, which are important for chopping food for both swallowing and digestion.

• The lower jaw is mobile and is suspended from the cranium by the two temporomandibular joints.

• The bony skeleton is covered by soft tissues of various thicknesses, including periostium, muscles, fat, and skin.

• Viscera of the facial area include the brain, the eyes, the oral structures, the major and minor salivary glands, as well as nerves, blood vessels, and lymphatics.

• Facial injuries may affect any of the above-noted structures. Familiarity with normal anatomy is the key to being able to reestablish it after it has been disrupted by an injury.

• Visceral injuries are managed to reestablish function.

• Soft tissue repair is done to reestablish covering and to minimize the visibility of any scars. Acute repair may require the use of local or other flaps or grafts.

• Facial nerve injuries should be identified early, and if there is a peripheral nerve injury, exploration and repair at the earliest opportunity should be considered

• Similarly, injuries to main salivary ducts should be explored and repaired.

• The focus is on the craniomaxillofacial (CMF) skeleton.

• For purposes of this chapter, the CMF skeleton is divided into three areas:

  1. Upper third: includes the forehead, including the frontal bones, supraorbital rims, and glabella.

  2. Middle third: includes the zygomas, maxillae, nasal bones, and orbits, and it can include the vertical rami of the mandible.

  3. Lower third: comprised of the mandible, generally anterior to the vertical rami.

• The nasal septum is a midline structure in both the middle and lower thirds.

Diagnosis

• Must assess ABCs first

• Always consider cervical spine injury

• Always assess neurological status and obtain consultation as indicated

  1. Clinical

  2. Observation

     • Obvious injuries

     • Soft tissue tears, loss

       ...