Concomitant Injuries to Facial Fractures

Too often in emergency room settings, the doctor looks at the most visible injury, such as a facial fracture and neglects the fact that concomitant injuries can have taken place as a result of the same forces or perhaps different forces acting on the human involved in motor vehicle fractures. In fact, many auto accident patients with facial fractures have other types of fractures that need management, perhaps even more acutely than the facial fracture.

Facial fractures can involve several parts of the face, including the mandible or jaw bone, which is six times more likely to be fractured than the maxilla or mid-face bone. In addition, a zygomatic bone fracture in the face occurs twice as often as maxillary fractures but only a third as much as mandible fractures. The force that breaks these bones in a car accident can push the bones into sinuses or through the facial bones into the skull.

Skull fractures can happen along with facial fractures and can be more severe in terms of morbidity and mortality. Those with skull fractures can have bleeding inside or around the brain that puts pressure on the brain structures. This excess pressure on the brain can lead to permanent brain damage or death from excess bleeding and swelling of the brain.

The forward forces involved in front end car accidents propel the face into the steering wheel or dash. They also can fracture portions of the cervical spine, especially in the anterior portion from extreme flexion that hits two vertebral bodies together. A cervical fracture also damages surrounding ligaments so that the neck becomes unstable. It can impinge on the spinal canal and can even lacerate the spinal cord, leading to a quadriplegic state, which is permanent in most cases.

Upper extremity fractures can occur along with facial fractures if the individual in a front end collision reaches out in front of them. The force on the arms can fracture the proximal or upper humerus, yielding a shoulder fracture. The midshaft of the humerus can be involved but this is less common than the upper humerus.

The elbow can also be fractured as part of the same forward momentum that causes a facial injury. Most elbow fractures involve fractures of the radius and ulna near the elbow. They can be fractured in situations where the arm is completely outstretched as in anticipating the accident. In addition, the hand and wrist can sustain injuries.

The trick to dealing with the multiply injured patient is to handle the injuries in decreasing order of severity, regardless of how a fracture looks. For example, a cervical fracture must be stabilized before definitive treatment of an open elbow fracture because the stabilization of the cervical spine can prevent serious neurological complications, including quadriplegia.

In some cases, surgery to correct the maxillofacial fracture can be combined with cervical stabilization in the operating room. During the same surgery time, the open fracture of the elbow can be reduced and surgically sutured. It involves the combined efforts of a number of types of surgeons.

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