Chapter 1
Facial trauma: incidence, aetiology and principles of treatment

Facial trauma is a challenging area of clinical practice. By its very nature, the highly visible effects it can have on both the function and aesthetics of the face means that any repair that is less than perfect will be all too apparent. Injuries to the nasoethmoid region are especially noticeable - the medial canthus needs only to drift a millimetre or so to become obvious. However, fractures are just one component of the spectrum of 'maxillofacial injuries'. They are variably associated with injuries to the overlying soft tissues and neighbouring structures such as the eyes, lacrimal apparatus, nasal airways, paranasal sinuses, tongue and various sensory and motor nerves.

The bones and tissues of the face support and maintain a number of key functions, including those relating to the oral cavity, nasal cavity and orbits. Not surprisingly, injuries to the face can have a major cosmetic impact and even so-called 'minor' injuries if poorly treated can result in significant disability and an unsightly appearance. When fractures extend into the skull base and involve the intracranial contents they are usually referred to as 'craniofacial' injuries. These will often require combined management with a neurosurgeon. Facial trauma can vary in severity therefore from a simple crack in a bone to major disruption of the entire facial skeleton with associated severe soft tissue injury.

Most facial injuries occur following relatively low energy impacts and require relatively straightforward treatment. However, despite high patient satisfaction rates, less than perfect results are still common. Clinicians treating these injuries should strive for the ideal goal of returning the patient to their pre-injury form and function. Unfortunately in many cases, especially when high energy injuries have resulted in both comminution of the facial skeleton and significant soft tissue damage, this cannot always be achieved. Despite major developments in the fields of tissue healing, biomaterials and surgical technology, there is still room for improvement.

Although fractures of the facial skeleton are common, they can easily be overlooked when accompanied by soft tissue swelling or lacerations. Delay in diagnosis can contribute to the likelihood of residual deformity and all doctors working in emergency departments should therefore be able to recognize these injuries, understand their significance and be familiar with basic management. Fractures of the lower jaw or alveolus may also present to a dental surgeon in general practice, or very rarely be a complication of a difficult tooth extraction. An understanding of facial fractures, as well as other facial injuries, has a practical application for many specialists therefore, and is not just of relevance to those studying for higher qualifications or those pursuing a career in specialist surgery.

When considering the topic of facial fractures parallels can be drawn with orthopaedic surgery. In a sense, management of facial trauma can be regarded as 'facial orthopaedics' and as such requires the same core knowledge of fracture management and application of similar treatment principles. These include an understanding of fracture healing, principles of fixation and an appreciation of the importance of the 'soft tissue envelope'. However, facial surgeons will also need to draw on their specialist aesthetic skills to ensure the best possible results, facilitating this by being as anatomically precise as possible.

Incidence

When considering trauma in all its forms maxillofacial injuries are not particularly common, although it is difficult to arrive at any accurate estimate of their global incidence. Estimates vary considerably both within and between countries. Reported incidences may also be skewed, depending on local referral pathways. Nasal fractures, for instance, are commonly treated by plastic surgeons and otorhinolaryngologists as well as oral and maxillofacial surgeons. As a result they may not be fully captured by any single database. There will also be a variation in the number of fractures treated by any particular specialist unit depending on geographical location, the demographics of the catchment population and seasonal factors. Generally speaking, the most common facial fractures are nasal and mandibular fractures, followed by injuries to the zygoma, maxilla and orbit. Dentoalveolar fractures are also common but may not present to specialist centres, so accurate figures are not widely available. Finally, the terminology used for recording injuries may add to the confusion about fracture incidence. For example, the term 'middle third fracture' is not anatomically precise and may be used to include fractures of the midface, orbito-zygomatic complex and fractures of the nose.

In one large study of patients sustaining injuries as a result of personal assault approximately 80% of all fractures and 66% of all lacerations were facial. Other prospective studies of severely injured patients have shown that a significant number of maxillofacial injuries may also be associated with life-threatening injuries elsewhere. Of these patients, approximately one fifth subsequently died while in hospital. This frequency of coexisting injuries may have major implications when considering transfer to specialist centres.

Aetiology

In many countries the common causes of fractures of the facial bones are interpersonal violence, sporting injuries, falls, motor vehicle collisions (road traffic accidents) and industrial or agricultural trauma. For the first 30 years after the World War II, motor vehicle collisions (MVC) were the major cause of maxillofacial injuries, accounting for between 35 and 60% of fractures of the facial bones. Following the introduction of alcohol, seat belt and crash helmet legislation, these patterns dramatically changed. Many longitudinal studies from countries such as the Netherlands, Germany and the UK have reported that economically prosperous countries have shown a striking reduction in motor vehicle collisions as a specific cause of facial injuries, while at the same time there has been an increase in interpersonal violence and sports related injuries.

The incidences and causes of facial bone fractures are mostly influenced by:

1. Geography.
2. Social trends.
3. Alcohol and drug abuse.
4. Road traffic legislation.
5. Seasons.

Geography

Numerous studies have now shown clear relationships between urban living and facial injuries, possibly linked to alcohol consumption and social deprivation. Not surprisingly agricultural-type injuries are more commonly seen in rural communities. In developing countries where there is a rapid increase in road traffic, motor vehicle related trauma is still a major cause of fractures. In some countries, notably in some states in the USA, gunshot trauma now exceeds road traffic accidents as a cause of facial injuries.

Social trends

In more recent years in urban areas, interpersonal violence has accounted for an increasing proportion of facial bone fractures. This includes domestic abuse. Data from a number of centres around the world suggests that interpersonal violence now accounts for more than half of all facial injuries seen in emergency departments. In the United Kingdom between 1977 and 1987 there was a 47% increase in maxillofacial injuries caused by assault, while simultaneously there was a 34% decrease in road accident victims with facial bone fractures. The relative incidence of other facial injuries, such as lacerations, has also been influenced by these trends.

Alcohol and drug abuse

In many countries alcohol and drug abuse are now major factors in the aetiology of traumatic injuries. Maxillofacial injuries are commoner in young men than any other group and to a large extent this is a reflection of the increased alcohol consumption by this section of society and the violence that may ensue. Indeed it has been said that 'the combination of alcohol and testosterone is a potent mix'. Alcohol and drugs may also be a significant factor in maxillofacial injuries sustained by road users. The influence of alcohol on maxillofacial trauma was clearly demonstrated in a large prospective study of 6114 facial injuries presenting over a period of one week to 163 UK emergency departments. Of these, 40% of facial injuries were caused by falls, a large proportion of which were in children under five years and occurred within the home. However, 24% of the injuries were caused by interpersonal violence, mainly in young adults. In this group alcohol consumption was implicated in some way in 55%. Only 5% of facial injuries were caused by road traffic accidents (RTA) with 15% of victims having consumed alcohol. The 15-25 age group suffered the greatest number of facial injuries due to either assault or RTA and had the highest number of injuries associated with alcohol consumption. Overall at least 22% of all facial injuries in all age groups were related to alcohol consumption within 4 hours of the injury.

Road traffic legislation

Vehicle safety design has been influenced both by research and legislation, and in many countries the use of seat belt restraint has now been made compulsory in law. Seat belts have resulted in a dramatic decrease in injuries overall and severe injury in particular and that general trend has been reflected in the incidence of...