Hot Seat #6 The Denouement: Facial Trauma

Naomi wrote this case about an adolescent who sustained facial injuries after being hit in the face by a line in a boat, knocking him unconscious briefly. His exam reveals several lacerations on his face and loose teeth. For the full case presentation, click here.

We presented practical questions about diagnostic and disposition plans. Here's how you responded.

1. Would you do any addition imaging or diagnostic testing?

2. To diagnose a maxillary fracture, what imaging modality would you use? 

3. After laceration repair, you find he has a non-displaced anterior maxillary fracture. What is your disposition plan?

Hot Seat Response
by Christina Johns

Whenever there's facial trauma I love to trot out the LeFort Fractures as some potential real live serious pathology. In this case, I'm worried about that with the right upper jaw mobility and dental trauma. Remember the classification? Here it is, courtesy of good old Wikipedia.

When I assess the face, in addition to checking for malocclusion I like to use a 2 hand exam where the finger of one hand is on the glabella and the other hand grabs hold of the maxillary dentition to check for instability. If there is any, my index of suspicion is heightened and I'm fairly quickly involving OMFS.

I'm wondering if this patient got any C-spine imaging, and I would really want to be careful about my cranial nerve exam too.

The other thing that bothers me is the neck swelling and "sensitivity." It's a little unusual and gets me started thinking about the different Zones in neck trauma-- there are a lot of structures that can be officially classified as "make me nervous" and although the zones really refer to penetrating trauma I think you would have to consider pseudo aneurysm of one of the vessels as well. I'll think more about this, but there's a lot that gets my attention here and early surgical involvement and consultation would be my inclination.

The Denouement
by Naomi Hughes

Plain films were done – chest, neck soft tissue, and facial – to look for lost tooth and to evaluate airway patency. We found no swallowed tooth and the airway was patent.

We ordered a maxillofacial CT that showed a nondisplaced anterior maxillary fracture. We consulted OMFS over the phone. They did not need to see the patient that night and scheduled a clinic appointment for 2 days later. The accident occurred on a Saturday and the patient would be seen by OMFS on Monday.
 
We started the patient on oral antibiotics, Augmentin. We did not get c-spine films because we were confident we could clear his c-spine clinically. We did no further advanced imaging. We admitted the patient to observation for neuro checks given LOC. Neuro exam remained stable. He did not develop stridor, difficulty swallowing or neck swelling from injury and was discharged the following day.

Please share your thoughts in the comments section below.