Head and Face Trauma: Assessment and Management

Maxillofacial injuries

Trauma to the facial skeleton including the jaw, cheekbones, nose, and eyes.

Airway Compromise

A critical concern in face and head trauma due to potential obstruction from soft-tissue injuries.

The Skull and Facial Bones

28 bones in three groups: 6 auditory ossicles (three on each side) and 22 bones making up the cranium and face.

Cranial Vault

Composed of eight bones (parietal (2), temporal (2), frontal, occipital, sphenoid, ethmoid). The foramen magnum is a crucial opening at the base.

Skull Joints (Sutures)

Include sagittal, coronal, and lambdoid sutures, along with structures like fontanelles and the mastoid process.

Floor of Cranial Vault

Divided into anterior, middle, and posterior fossae, containing structures like the crista galli, cribriform plate, olfactory nerves, and nasal cavity.

Base of the Skull

Features occipital condyles, hard palate, and zygomatic arch.

Facial Bones

14 bones form the face's structure, including maxilla, vomer, inferior nasal concha, zygomatic, palatine, nasal, and lacrimal bones. The zygomatic arch is also mentioned.

Facial nerve (seventh cranial nerve)

Controls motor activity of facial expression muscles and taste to the anterior two-thirds of the tongue.

Blood Supply of the Face

Primarily through the external carotid artery and its branches (temporal, mandibular, maxillary arteries).

Trigeminal nerve

The fifth cranial nerve responsible for sensory and motor functions of the face.

Orbital floor

The bottom part of the eye socket, which can be fractured resulting in blowout fractures.

Hyphema

Blood in the anterior chamber of the eye, can result from blunt eye injuries.

Larynx

The voice box located in the anterior neck, critical for airway management.

Nasal Fractures

Most common facial fracture, structurally unsound nasal bones. May cause severe nosebleed (epistaxis) and "airway issues."

Mandibular Fractures and Dislocations

Second most common. Result from blunt force trauma to lower third of face (common in assaults). Suspect with dental malocclusion, chin numbness, inability to open mouth.

Maxillary Fractures

Massive blunt facial trauma (e.g., MVCs). Signs include massive facial swelling, midfacial instability, malocclusion, elongated face. Classified by Le Fort I, II, and III fractures.

Orbital Fractures

Patients may report "double vision (diplopia)" or "loss of sensation" around the eyebrow/cheek. Inferior orbit fractures (blowout fractures) are common and "can cause paralysis of upward gaze."

Zygomatic Fractures

Fractures of the cheek bone, commonly from blunt trauma. Signs include flattened face, paraesthesia/loss of sensation over cheek/nose/upper lip, and "paralysis of upward gaze."

Soft-tissue injuries

Lacerations, avulsions, contusions. Pinna has poor blood supply, and cartilaginous pinna healing can be complicated by infection.

Eardrum Rupture (Tympanic Membrane Perforation):

Caused by foreign bodies, blast injury, barotrauma. Signs include hearing loss and blood drainage from ear. "Extremely painful, heals spontaneously."

Dental Injury

Fractured and avulsed anterior teeth common after facial trauma. Assess the striking individual in assault cases (bacteria risk). "Tooth fragments in wound."

Closed Head Injury

Most common (blunt trauma). Dura mater intact, brain tissue not exposed. Includes skull fractures, focal or diffuse brain injuries. "Often complicated by increased ICP."

 Open Head Injury

Dura mater and cranial contents penetrated, brain tissue exposed. Most common from gunshot wounds. "High mortality rate," survivors often have neurologic deficits.

Scalp Lacerations

Can cause significant blood loss (rich blood supply), leading to "hypovolemic shock" (more common in children). Often associated with deeper injuries.

Skull Fractures

Four types: Linear, Depressed, Basilar, Open. Significance depends on fracture type, force, and area.

 Linear

Nondisplaced (80% of all skull fractures, 50% in temporal-parietal). Radiographic evaluation needed; benign if brain uninjured/scalp intact. Infection risk with laceration.

Depressed

High-energy, direct trauma (small surface area). Frontal/parietal most susceptible. Bony fragments driven into skull. Neurologic signs (LOC) often present.

Basilar

High-energy, diffuse impact (falls). Extension of linear fracture to skull base. Difficult to diagnose. Signs include "CSF drainage from ears," "Raccoon or panda eyes," and "Battle sign."

    ◦ Open: Severe forces. Often associated with multitrauma. Brain tissue may be exposed, high infection/mortality rates.

Traumatic Brain Injury (TBI)

"An insult to the brain that can produce Physical, intellectual, emotional, social, and vocational changes."

    ◦ Primary Injury: Instantaneous from impact.

    ◦ Secondary Injury: Consequence of primary injury cerebral edema, intracranial hemorrhage, increased ICP, ischemia, hypoxia, hypoglycemia, hypotension, infection).

Injury to Brain

Penetration or indirectly by external force. Includes "Coup–contrecoup injury" (front-and-rear). Can lead to cerebral edema and vasodilation.

Intracranial Pressure (ICP)

Normal adult ICP is 5-15 mm Hg. "No room for expansion in cranium." Increased ICP "decreases brain perfusion." Brain requires constant oxygen supply.

Cerebral Perfusion Pressure (CPP)

Pressure of blood flow through brain. CPP = MAP – ICP. Critical minimum threshold is 60 mm Hg; below this, "cerebral ischemia occurs."

Cerebral Herniation

Brain forced from cranial vault through foramen magnum or over tentorium.

Cerebral concussion

Rapid acceleration-deceleration forces causing transient cerebral cortex dysfunction. Signs: transient confusion, disorientation, LOC, retrograde/anterograde amnesia.

Diffuse axonal injury (DAI)

More severe than concussion, poor prognosis. Stretching, shearing, tearing of nerve fibers (axonal damage). Classified as mild, moderate, or severe.

Focal Brain Injury

Specific, clearly defined, visible on CT scan.

Cerebral Contusions

Bruised/damaged brain tissue in a specific area (often frontal lobe). Leads to greater neurologic deficits and ICP problems.

Intracranial Hemorrhage

Bleeding within the skull (no room for accumulation). Increases ICP.

Epidural Hemorrhage

Between skull and dura mater (0.5-1.0% of head injuries). Usually blow to head with linear fracture (common at temporal bones due to middle meningeal artery involvement). Signs: LOC, lucid interval, unresponsiveness, fixed/dilated pupil on hematoma side. "Death if pressure not relieved surgically.

Subdural Hematoma

Beneath dura mater, outside brain (5% of head injuries). Rupture of bridging veins; venous bleeding is slower. Signs: fluctuating LOC, focal neurologic signs (hemiparesis), slurred speech.

Intracerebral Hemorrhage

Within brain tissue (penetration injury, rapid deceleration). Can occur with DAI. Frontal/temporal lobes most affected. Rapid deterioration once symptoms appear. High mortality rate.

Subarachnoid Hemorrhage

Bleeding into CSF circulation (bloody CSF). Sudden, severe headache (later diffuse). Increased ICP, decreased LOC, pupil changes, posturing, vomiting, seizures. "Sudden, severe subarachnoid hemorrhage usually results in death."

Glasgow Coma Scale (GCS)

A scale for assessing the level of consciousness in a patient.

Avulsed Tooth Management

Reimplantation is possible within 1 hour; handle by the crown, rinse gently and keep moist.

Blowout fractures

Fractures of the orbital floor leading to displacement of the eye and potential double vision.

Facial Fractures

Common injuries resulting from trauma that present with symptoms like facial asymmetry and instability.

Impaled Objects

Foreign objects lodged in the tissue that should not be removed without medical assistance.

Occlusive Dressing

A sterile covering applied to open neck wounds to prevent air embolism and restore integrity.

Hypovolemic Shock

A condition resulting from significant blood loss, which may occur due to severe facial and head injuries.

Conjunctivitis

An inflammation of the conjunctiva, sometimes resulting from foreign objects in the eye.