Neck and facial trauma

• Neck and facial trauma is a cluster of injuries rather than a single disease: a penetrating neck wound can exsanguinate or occlude the airway within minutes, while facial fractures, dental injuries and a nasal septal haematoma threaten the airway, the eye and the long-term shape of the face.
• Anatomical boundaries, not appearances, define severity. In the neck, violation of the platysma (the thin sheet of muscle just under the skin) makes a soft-tissue wound a penetrating neck injury. In the abdomen the equivalent boundary is the anterior fascia; in the face the equivalent caution is any fracture extending into the tooth socket or the paranasal sinuses.
• Modern care is driven by hard signs of vascular or airway injury: an expanding haematoma, severe or uncontrolled bleeding, shock not responding to fluids, an absent pulse, a bruit or thrill, airway compromise and cerebral ischaemia all mandate immediate operative exploration. Absence of hard signs in a stable patient permits imaging and observation. ^[1]
• Facial fractures follow the ATLS (Advanced Trauma Life Support) primary survey: airway first, because blood, swelling and displaced bone can obstruct dynamically. A levered-back maxilla can block the pharynx, and bilateral mandibular fractures can let the tongue fall backwards.
• Timing matters for specific complications: a nasal septal haematoma and a paediatric trapdoor orbital fracture each need drainage or release within 24 to 48 hours, and an orbital compartment syndrome needs decompression within one to two hours. A matchstick or an avulsed tooth has a window measured in minutes, not hours. ^[3]
• Advanced Trauma Life Support 11th edition (2025) frames the whole assessment as xABCDE, placing control of exsanguinating haemorrhage before airway, and the AO CMF (cranio-maxillofacial) and EAST (Eastern Association for the Surgery of Trauma) references used here are the current editions the authors could access.

By the end of this page you should be able to:

1. Classify a penetrating neck injury by the three classical zones and by the structures at risk in each zone, and explain why the modern "no zone" approach still uses them for anatomy.
2. Distinguish hard from soft signs after penetrating neck injury and state their immediate management, including permissive hypotension, Foley catheter tamponade and CT angiography.
3. Plan the emergency airway in a patient with neck or facial trauma, including the safe use of video laryngoscopy, awake fiberoptic intubation, cricothyroidotomy and nasotracheal intubation.
4. Recognise Le Fort I, II and III, mandibular, orbital blow-out, nasal and dental injuries clinically, choose appropriate imaging, and state the indications and time limits for repair.
5. Manage a nasal septal haematoma, dental avulsion, and orbital compartment syndrome as emergencies.
6. Outline management in children, older adults and low-resource settings.

Penetrating neck injury is defined as an injury caused by a missile that penetrates the platysma muscle, anywhere from the base of the skull to the sternum. A wound that does not breach the platysma is a superficial soft-tissue injury. A substantial proportion of wounds that look minor still need expert assessment because a stable patient can deteriorate rapidly. This material extends the more general penetrating trauma page; the neck is treated here on its own because its compact anatomy makes it a distinct problem.

Facial trauma includes injuries to the soft tissues of the face and scalp (which account for half of the wounds treated in emergency departments), fractures of the facial skeleton, dental and alveolar injuries, and injuries of the nasal septum, orbits, lacrimal system and facial nerve.

The classical zones of the neck remain the anatomical framework. Their modern role is to predict access and the structures at risk, rather than to mandate automatic exploration.

Hard and soft signs of injury to vital structures are the basis of modern management. Hard signs demand immediate operation; soft signs in a stable patient lead to imaging. ^[1]

Facial fractures are classified anatomically rather than by a single severity score. The Le Fort system (AO CMF describes it as a historic classification, still widely used, derived from experimental frontal impacts on cadavers) divides midface fractures into Le Fort I, II and III. ^[7] Mandibular fractures are described by site (condylar process, coronoid, ramus, body, angle, symphysis/parasymphyseal) and by whether they are single or multiple. Orbital fractures are grouped by wall and by mechanism (rim, floor, medial wall, roof, NOE complex). Of these, the Le Fort, mandible site, orbital wall plus entrapment status and the NOE Markowitz type (I to III, based on the medial canthal tendon attachment) are the severity markers used in practice. ^[3][4]

A patient does not have one "stage" but a list of injuries to be addressed in priority order: life threats first, then function and cosmesis. The facial soft-tissue examination, dental occlusion, eye movements, visual acuity and nasal septum are checked even when the bony diagnosis appears obvious.

Penetrating neck injury is uncommon but serious. Isolated neck injuries represent up to 10% of all trauma cases, with mortality as high as 10%; the mortality of a penetrating neck injury overall is 3-6%. Vascular injury occurs in up to 25% of cases, usually carotid before vertebral; aerodigestive injury in 23-30%; half of deaths follow haemorrhage from vascular injuries, and carotid artery injury is reported in 10%. ^[1] Stab wounds cause significant injury in only 10-20% of cases, compared with 35-50% of gunshot wounds. ^[1] Aerodigestive injuries carry a higher mortality of 11-17%. ^[1]

Maxillofacial trauma shows consistent patterns. In adult Europe the leading mechanisms are assaults (39%), falls (31%), motor vehicle accidents (11%), sport (11%) and work (3%), with a male-to-female ratio of 2 to 1. In developing countries motor vehicle accidents predominate (73.8%). ^[3] Globally, paediatric cases (0-16 years) are led by motor vehicle accidents (33.8%), falls (20.7%), violence (9.9%) and sport (8.1%). ^[3] In adults over 75 years, household falls account for 83.5% of cases, with a female predominance. ^[3] Nasal fractures are the most common facial fracture, and maxillofacial trauma is reported as 1.4-11% associated with life-threatening haemorrhage. ^[3]

Associated injuries are frequent: thoracic injuries occur in up to 15% of major facial trauma, and orbital fractures carry associated ocular injuries in up to 29% of patients, with blindness in up to 10%. ^[3][4] Le Fort fractures have reported mortality of 0% for Type I, 4.5% for Type II and 8.7% for Type III. ^[3]

Dental trauma peaks at 7-11 years of age, with a male-to-female ratio of about 2 to 1. ^[5] Permanent teeth are injured more often than primary teeth (60% versus 40%), and in one emergency department series 24% of major trauma patients had dental injuries, two-thirds of them avulsions. ^[5]

Paediatric facial fractures are rare overall: 1-14% of trauma victims under 16 years of age, and 0.87-1.00% under 5 years. ^[3] Conversely, 85-92% of paediatric facial trauma is soft-tissue injury rather than fracture. ^[3]

Mechanism and energy determine everything. Stab wounds are low velocity; gunshot wounds are high velocity with cavitation; blast injuries combine all mechanisms and cause multiple injuries. Falls, assaults, sport, road traffic crashes and work accidents are the leading mechanisms, with distinct national patterns as above. Anatomic risk factors for dental trauma include an anterior open bite, Class II malocclusion, prominent upper incisors and incompetent lips. ^[5]

Repeated and delayed risk comes from under-treatment: the AO CMF group notes that the appropriate window for primary fracture repair is limited to two weeks, after which the case becomes a delayed reconstruction. ^[7]

Head injury and cervical spine injury must always be excluded before craniomaxillofacial treatment begins. ^[7] A penetrating neck injury is frequently one injury in a polymechanism list: blast and high-velocity trauma produce multiple entries.

The neck is an anatomical corridor. The common carotid and internal carotid arteries, the internal jugular veins, the trachea, the oesophagus and multiple nerves occupy a small space surrounded by fascia, so a penetrating tract can injure several systems at once. Arterial injury produces rapid haemorrhage and cerebral ischaemia; venous injury produces bleeding and air embolus. Partial-thickness vascular wounds may form pseudoaneurysms, dissections or arteriovenous fistulas, and clot may dislodge. ^[1]

Airway obstruction in penetrating neck injury has three mechanisms: direct laryngotracheal injury, expanding haematoma compressing the airway, and bleeding into the pharynx. Blood and secretions also obstruct by flooding. These are dynamic and can evolve in minutes, which makes early airway control sensible. A common error is to delay for a "good look"; the neck can decompensate quickly.

Maxillofacial pathophysiology is dominated by the same airway theme. Obstruction arises from posterior displacement of the tongue in bilateral mandibular fractures, a sublingual haematoma, blood clots, a fractured maxilla pushed backwards towards the pharyngeal wall (as in severe Le Fort patterns), soft-tissue swelling and foreign material such as teeth or bone. ^[3] Because these are dynamic, the airway must be reassessed repeatedly rather than only once.

Fracture mechanics explain the patterns. The orbital floor is a thin plate over the maxillary sinus; hydraulic forces through the globe (the Pfeiffer mechanism) or buckling of the rim (the Le Fort mechanism) either blow out the floor with an intact rim or fracture the rim itself. ^[4] Trapdoor fractures occur when elastic bone in children and young people fractures linearly and recoils, trapping orbital contents. ^[4] The NOE (naso-orbito-ethmoid) complex depends on the medial canthal tendon to maintain intercanthal distance and eyelid shape. ^[4]

Nasal septal haematoma is a collection of blood beneath the mucoperichondrium of the septum. It separates the cartilage from its blood supply, so untreated it leads to avascular cartilage necrosis, septal perforation, abscess and saddle nose deformity. ^[3]

Dental trauma arises from direct or indirect impact. The periodontal ligament (PDL) connects cementum to alveolar bone; PDL cells desiccate in open air within minutes, which is why storage and time determine survival of an avulsed tooth. ^[5]

Hard signs dominate the first assessment (see table). Soft signs include haemoptysis, haematemesis, oropharyngeal blood, dyspnoea, dysphonia, dysphagia, subcutaneous or mediastinal air, a chest tube air leak, a non-expanding haematoma and focal neurological deficits. ^[1] A patient with a small stable haematoma in Zone III is not the same emergency as one with an expanding neck haematoma and stridor.

Clinical airway indicators of impending collapse are stridor, hoarseness, bubbling from the wound, worsening tracheal deviation and subcutaneous emphysema. ^[1] Permissive hypotension with a systolic blood pressure around 90 mmHg, while bleeding is uncontrolled, is appropriate in penetrating neck trauma because higher pressures can dislodge a haemostatic clot. ^[1]

The secondary survey of the head and face is a full inspection and palpation: scalp lacerations, skull deformity, fractures, eye injury, dental trauma, nasal bleeding, CSF rhinorrhoea or otorrhoea, pupillary signs and haemotympanum.

Maxillofacial findings by fracture type (from current emergency medicine review of facial trauma): ^[3]

• Le Fort I (maxillary): movement of the maxilla, floating palate, a mobile tooth-bearing maxilla and hard palate, malocclusion, dental fractures.
• Le Fort II (pyramidal): movement of the nasal complex and maxilla, malocclusion, extraocular, lacrimal and septal complications.
• Le Fort III (craniofacial disjunction): movement of the midface and orbital rims, malocclusion.
• Orbital: bony tenderness, swelling, ecchymosis, reduced acuity, diplopia, enophthalmos, periorbital emphysema, limitation of eye movements.
• Mandibular: pain with jaw movement or trismus, malocclusion, lip and chin sensory problems, sublingual haematoma, dental or alveolar ridge fractures, loose or missing teeth, haemotympanum.
• Nasal: external lacerations, nasal dorsum asymmetry, periorbital ecchymosis, septal haematoma.
• Superior/rural concern: a subjective feeling that the "bite feels off" is a highly sensitive guide to mandibular fracture; a sublingual haematoma is highly suggestive of a mandibular fracture. ^[3]

Ocular findings needing immediate action: severe pain, proptosis, tense globe and visual loss point to orbital compartment syndrome. Paediatric trapdoor fractures present with surprisingly few external signs ("white-eyed" blow-out) but restricted vertical gaze and possible oculocardiac reflex (bradycardia, nausea, syncope, asystole risk). ^[3][4]

A nasal septal haematoma appears as a fluctuant red or blue bulge along the septum, often within 24-72 hours after injury, and the nose remains obstructed despite vasoconstrictors and clot removal. ^[3]

Dental findings: note loose, displaced or missing teeth. A missing tooth must be accounted for: aspiration, ingestion or intrusion into the alveolus. ^[5]

Penetrating neck injuries are mistaken for superficial wounds when the platysma is not carefully inspected; conversely, skin bleeding can be dramatic with no deep injury. Cervical spine injury must be considered in every patient and most often is excluded clinically or with imaging.

Facial fractures overlap. A midface with mobility and malocclusion may be Le Fort II rather than I, and unilateral Le Fort II/III mixtures are common. The differential for posterior facial pain and malocclusion includes mandibular condylar fracture, which can be missed in older people. Orbital floor fractures must be distinguished from inferior rectus entrapment and globe injury; a medial wall fracture can be silent. A nasal septal haematoma can be confused with mucosal swelling or a septal abscess. An avulsed tooth can be mistaken for an intruded one, or swallowed or aspirated if not found.

The mechanism also argues for broad differentials: the same blunt trauma that fractures the face can produce intracranial bleeding, cervical injury, thoracic injury and orbital compartment syndrome.

Airway and neck. Fiberoptic or video-assisted laryngoscopy is used where available, and capnography is mandatory. Bedside ultrasound (FAST, the focused assessment with sonography for trauma) and chest imaging evaluate thoracic injuries. ^[3]

Neck vascular and aerodigestive imaging. Multidetector CT angiography of the neck is the key investigation in stable patients: the American College of Radiology cites a 90-100% sensitivity and 98.6-100% specificity for vascular injury, and a 100% sensitivity (specificity 93.5-97.5%) for aerodigestive injury. ^[1] If the missile tract lies near pharyngoesophageal structures, sensitivity drops to as low as 53% and further evaluation with contrast esophagram followed by esophagoscopy is mandatory. ^[1] Digital subtraction angiography and triple endoscopy (laryngoscopy, bronchoscopy, oesophagoscopy) are reserved for diagnostic uncertainty. ^[1][6] CT of the neck without angiography can exclude a significant vascular injury when it shows the trajectory is remote from vital structures, though minor injuries such as intimal flaps may be missed. ^[6] Contrast esophagography or esophagoscopy detects oesophageal perforation, but morbidity rises if repair is delayed beyond 24 hours. ^[6]

Facial imaging. CT of the face with axial, coronal, sagittal and 3D reconstructions maximises sensitivity to more than 90% of facial fractures. ^[3] Plain radiographs are not first choice for complex facial trauma and may miss up to 38% of fractures. ^[3] For mandibular fractures, a panoramic radiograph plus anteroposterior mandible films can be reasonable when suspicion is low. ^[3] Cervical spine imaging (by standard trauma rules) is required in major trauma and when distracting injuries exist. ^[3] C-spine imaging in penetrating trauma follows the mechanism: unstable cervical spine fracture after penetrating neck injury is rare (about 7% when other injuries coexist, 1.5% when isolated). ^[1]

Ocular and neurological. Visual acuity (one eye at a time), extraocular movements, pupillary reflexes, intraocular pressure and fluorescein examination evaluate eye injury. Any CT evidence of intraconal bleeding requires urgent ophthalmology or maxillofacial consultation to exclude orbital compartment syndrome, whatever the clinical presentation. ^[3] Beta-2 transferrin testing confirms CSF: its specificity is 97% and sensitivity 99%. ^[4]

Laboratory. Full blood count, coagulation studies, group and hold, blood gases and lactate support resuscitation; blood cultures if infected neck or tumour of the tumour is suspected.

There is no universal severity score for neck or facial trauma; assessment combines the hard/soft sign classification in penetrating neck injury with anatomical classification in facial fractures.

• Penetrating neck injury. Platysma violation defines the injury. ^[1] Hard signs mandate operation; soft signs lead to imaging and observation.
• Le Fort. I, II or III by the fracture pattern. ^[3][7]
• Mandible. Site plus single versus multiple; condylar subtypes; whether displacement produces malocclusion. ^[3]
• Orbit. Wall (floor, medial, rim, roof, NOE); entrapment on forced duction; degree of volume loss. Repair usually follows when hypophthalmos exceeds 2 mm or more than 50% of the orbital floor is involved. ^[4]
• NOE (Markowitz). Type I intact medial canthal tendon; II comminution with tendon attached; III severe comminution with tendon avulsed. ^[4]
• Nasal. Simple (unilateral), complex, comminuted or telescoped septal; associated NOE or CSF leak. ^[3]
• Dental. By tissue: enamel, dentine, pulp (fracture), luxation classification (concussion, subluxation, extrusive, lateral, intrusive), and avulsion. ^[5]

A useful added check: in the secondary survey, search for the injury the primary survey hides. Distracting injuries are common, and cervical spine clearance should not be assumed without examination or imaging.

ATLS principles govern the first minutes. Airway first, except when exsanguinating external haemorrhage demands control first: the ATLS 11th edition (2025) frames this as xABCDE, with exsanguinating haemorrhage before airway, breathing, circulation, disability and exposure. ^[2] The 11th edition is a transition to a physiology-driven model; its 10th edition was published in 2018. ^[2] Balanced resuscitation, permissive hypotension, tranexamic acid within 3 hours of injury, and early video laryngoscopy all follow from it. ^[2]

In maxillofacial trauma the same structure applies, but each step carries special content: airway assessment for obstruction; breathing including stridor and a two-person bag-mask technique; circulation including haemorrhage control; disability including GCS; exposure and environment including temperature in the lethal triad. ^[3]

Airway obstruction is common and dynamic, and it is the main cause of death in severe facial trauma. ^[3] Principles from current reviews and the ATLS 11th edition: ^[1][2][3]

• Suction the airway, remove blood and foreign material, and be prepared to escalate immediately.
• Video laryngoscopy (or video-assisted laryngoscopy) improves glottic visualisation in maxillofacial trauma where direct laryngoscopy is hard, and it minimises cervical spine movement. ^[2][3]
• Nasotracheal intubation is usually contraindicated with comminuted midface fractures because of the risk of iatrogenic penetration through a skull-base fracture, though several studies have challenged this absolute ban. ^[3]
• Modified rapid sequence induction with ketamine or etomidate preserves respiratory drive and haemodynamic stability. ^[3]
• Awake fiberoptic intubation is appropriate for anticipated difficult airways, and face-to-face awake intubation in the upright position is used for cooperative patients who cannot lie flat because of bleeding or aspiration risk. ^[3]
• Recognise a "cannot intubate, cannot oxygenate" situation early and progress to surgical airway; cricothyroidotomy equipment must be immediately available. ^[3]
• Blind intubation should never be attempted in penetrating neck injury; cricothyroidotomy is the preferred invasive airway, with success rates above 80% in experienced hands. ^[1]
• Bag-mask ventilation can worsen aerodigestive injury or dissection of air into the neck; if intubation is delayed, its use should be minimised. ^[1]
• A tracheal wound may allow intubation through the existing laceration as a temporising measure. ^[1]
• External cervical collar may worsen airway management; manual in-line stabilisation is preferred for severe midface or bilateral mandibular fractures, with immediate assessment after collar placement. ^[3]
• Cervical spine immobilisation is unnecessary after penetrating neck injury unless there is an overt neurological deficit or an unexaminable patient; collar placement can also hide expanding haematoma, subcutaneous emphysema and tracheal deviation. ^[1][6]

Direct pressure and haemostatic dressings are first. A Foley catheter inserted into the wound and inflated is a recognised temporising measure in the bleeding patient. ^[1] Permissive hypotension (around 90 mmHg systolic) is acceptable while bleeding is being controlled. ^[1] Impaled objects must not be removed; removal can convert a tamponade into fatal haemorrhage. ^[1]

Hard signs mandate immediate operation, preferably in theatre with vascular, otolaryngology, neurosurgical or cardiothoracic support as needed. ^[1] Soft signs and no signs in a stable patient lead to CT angiography; absent findings allow observation, provided the missile tract is not close to pharyngoesophageal structures. ^[1][6]

Specific vascular repair principles: partial carotid injuries less than 25% of diameter can be repaired primarily after debridement; larger injuries or loss beyond 1 cm need reconstruction or ligation, with temporary shunting when stable. Stroke rates with carotid injury are 6-12%. Internal carotid arteries are repaired when possible, and vertebral arteries may need endovascular or operative ligation; external carotids can be ligated. Venous injuries (jugular) are ligated if not bilateral. Tracheal and oesophageal repairs are primary when small and clean, or resection and anastomosis when more than half the circumference is lost. ^[1]

An EAST practice management guideline (2008) supports selective management of Zone II injuries as safe, with CT angiography or duplex ultrasonography in place of arteriography and high-resolution CT angiography as the initial study of choice, plus expeditious work-up because morbidity rises after 24 hours. Physical examination is more than 95% sensitive for arterial injuries requiring repair but inadequate to exclude aerodigestive injury. ^[6]

ATLS and AO CMF principles: life-threatening injuries first; definitive fracture repair only when the patient's condition allows, within a two-week window for primary treatment. ^[3][7] Triage of cranio-maxillofacial injuries in the AO reference is: ^[7]

• Immediate: haemorrhage control, surgical airway for midface fractures, lateral canthotomy for retrobulbar haemorrhage with excess orbital pressure.
• Within a few hours: heavily contaminated wounds, extraoral open fractures.
• Can wait 24 hours: simple, aseptic fractures.
• More than 24 hours: haemodynamically unstable patients.

Maxillofacial haemorrhage occurs in 1.4-11% of cases and is controlled by pressure packing, manual fracture reduction, balloon tamponade, angiography with embolisation or direct external carotid ligation. Nasopharyngeal bleeding can be tamponaded with epistats or Foley catheters, with care when cribriform fracture is possible. ^[3]

Antibiotic prophylaxis is for open fractures (any fracture extending to a tooth socket or associated with dental trauma) and contaminated wounds; duration is generally not more than 24 hours for clean open fractures, rising to 3-5 days for contaminated water, soil, mammalian bites. ^[3] Tetanus prophylaxis follows standard categories: low-risk wound needs a booster only after 10 years, high-risk (penetrating, contaminated) after 5 years, with tetanus immune globulin added for non-immunised or high-risk wounds. ^{[3] [5]}

Le Fort fractures. Patients are at risk of airway obstruction and haemorrhage. ^[3] In severe patterns the maxilla is pushed backwards, obstructing the pharynx; reduction (pulling the maxilla forward) relieves it, while bite blocks should be avoided because they may displace fragments and worsen bleeding. ^[3] All patients need cervical spine and intracranial assessment, and ophthalmology or maxillofacial review because visual complications overlap. Surgery within two weeks restores occlusion and facial buttresses; after that, secondary reconstruction. ^[7]

Mandibular fractures. Airway obstruction from posterior displacement of the tongue and central segment is the chief danger; it is relieved with anterior traction, manual jaw manipulation or jaw thrust. ^[3] Fixation (open reduction internal fixation or maxillomandibular fixation) aims at restoring occlusion; surgery is usually required for displaced fractures. The high predictive value of malocclusion, trismus and step-off arises from the combination of findings. ^[3]

Orbital fractures. Isolated orbital floor or medial wall fractures with normal vision, no entrapment, no compartment syndrome and normal globe position usually do not need emergency surgery and can be reviewed within a few days. ^[3][4] Emergency indications: optic nerve or globe threat, orbital compartment syndrome (lateral canthotomy plus cantholysis, urgent decompression), trapdoor entrapment (urgent surgery within 24-48 hours), retrobulbar haematoma, large volume loss or cosmetically significant deformity. Repair follows the threshold of more than 2 mm of hypophthalmos or more than 50% of floor involvement. ^[3][4]

Nasal fractures. Reduction is ideally performed early, before callus sets, typically within the time frames used by local ENT services. Exact timing is guided by swelling resolution and department protocol; the key emergency message is that reduction becomes difficult after about 7-10 days. Because that specific interval was not confirmed in the sources used here, department local guidance and ENT opinion determine it. What is explicit: septal haematoma must be drained urgently within 24-48 hours. ^[3]

Dental trauma. Replantation is the treatment of choice for an avulsed permanent tooth. ^[5] Most teeth replant successfully if the extraoral dry time is less than 30 minutes; after that probability falls, and periodontal ligament cells are irreversibly damaged after 30-60 minutes. Storage in an isotonic solution (milk, saline or saliva) while awaiting replantation slows cell death; water damages the ligament because of its low osmolality. ^[5] Primary teeth should not be replanted because of damage to the underlying permanent tooth germ. ^[5] Splinting time is 2 weeks (4 weeks if dry time exceeded 60 minutes); flexible splinting is recommended for all dental injuries. ^[5] Systemic antibiotics (doxycycline for 5 days, or amoxicillin) are used, with a reduced doxycycline dose in children under 50 kg (100 mg on day 1, 50 mg for 4 days). ^[5] Tetanus immune status should be updated. ^[5] Dental trauma mechanisms are the same as other facial trauma (falls, sport, road traffic, assault), and mouth guards reduce incidence. ^[5]

Aspiration or incision and drainage should be performed as soon as the diagnosis is made, ideally within 24-48 hours, with packing and follow-up to prevent re-accumulation. ^[3] Cartilage necrosis and saddle nose deformity are the consequence of delay. The emergency physician should check the septum in every nasal trauma. ^[3]

A CT scan may not be available; clinical assessment and plain radiographs (or basic mandibular series) then carry more weight. In penetrating neck injury, hard-sign assessment does not need a scanner and should drive theatre transfer. Direct pressure and a Foley catheter achieve temporising control. Simple, aseptic fractures can await transfer for 24 hours or more if the patient is stable. ^[1][7] In children, a conservative expectation that most facial trauma is soft tissue reduces unnecessary radiation; in older adults, low-energy falls mean lighter imaging when mechanism and exam are reassuring, but intracranial imaging is needed with anticoagulation or altered mental status. ^[3] Dental replantation can be performed in any emergency department with local anaesthesia, milk and a follow-up plan.

• Airway obstruction (swelling, haematoma, posterior tongue, displaced maxilla) in the immediate period. ^[1][3]
• Haemorrhage and shock, including uncontrolled external bleeding and occult retropharyngeal or orbital haematoma. ^[1]
• Vascular complications: pseudoaneurysm, dissection, AV fistula, stroke (6-12% after carotid injury). ^[1]
• Cerebral ischaemia and stroke from carotid or vertebral injury. ^[1]
• Aerodigestive injury (larynx, pharynx, trachea, oesophagus) with mediastinal contamination and a 11-17% mortality. ^[1]
• Orbital compartment syndrome with vision loss if not decompressed within one to two hours; trapdoor entrapment causing fibrosis and permanent diplopia after 24-48 hours; oculocardiac reflex. ^[3][4]
• Visual loss, hyphema, traumatic optic neuropathy, lens dislocation. ^[3]
• Non-union, malunion, malocclusion, midface collapse, saddle nose deformity, septal perforation, cerebrospinal fluid fistula. ^[3][4]
• Infection: abscess after septal haematoma, orbital, or open mandibular fracture; osteomyelitis. ^[3]
• Dental: pulp necrosis, replacement or inflammatory root resorption, ankylosis, tooth loss after avulsion; all strongly time dependent. ^[5]
• Neurological deficits: facial nerve branch injury, lacrimal drainage problems, anosmia after NOE injury. ^[3][4]
• Cosmetic deformity and chronic pain.

Outcome depends on mechanism, energy, number of structures involved, and speed of specific interventions. Penetrating neck injury mortality is 3-6%, with half of deaths from vascular haemorrhage and higher mortality when aerodigestive structures are injured. ^[1] Facial fractures differ: Le Fort I mortality is low (0% reported), II around 4.5% and III around 8.7% in large series, reflecting energy and associated injuries. ^[3] Orbital repair outcomes are good with timely release of entrapment and anatomical volume restoration; delayed repairs are technically harder. ^[4] Dental survival after avulsion is highly sensitive to dry time, with long-term survival reported as low as 20% in some series because of inadequate follow-up. ^[5] Most soft-tissue facial injuries and uncomplicated nasal bone fractures heal well without long-term disability.

• Road traffic safety, seat belts, airbags and helmets reduce high-energy facial and dental trauma. ^[3]
• Mouth guards reduce dental trauma in sport; helmets have not reduced dental trauma in the same way. ^[5]
• Violence and alcohol are recurrent precipitants in several mechanisms and populations; injury prevention programmes reduce assaults and falls. ^[3]
• Early intervention windows (septal haematoma drainage, trapdoor release, orbital decompression) are prevention of permanent sequelae rather than of the injury itself.
• Screening after a punch or a fall in an older person should include cognition, vision, osteoporosis, anticoagulation and home hazards. ^[3]

Children. Paediatric facial fractures are uncommon; 1-14% under 16 years and under 1% under 5, because the skull dominates the face and bones are elastic. ^[3] Greenstick and trapdoor fractures are more likely, and the white-eyed blow-out fracture with oculocardiac reflex is a paediatric surgical emergency. ^[3][4] Airway anatomy is precarious (small airways, large tongues) and the threshold to intervene is lower. ^[3] Suspicion of non-accidental injury must be considered in dental and facial trauma in young children. ^[5]

Older adults. Low-energy household falls (83.5% of facial trauma over 75) produce midface and orbital fractures, especially in women with osteoporosis. ^[3] Anticoagulation and antiplatelet therapy raise the risk of retrobulbar, nasal and intracranial bleeding. Intracranial imaging should accompany facial CT when mental status is altered or anticoagulation is present. ^[3]

Pregnancy. ATLS principles still apply; resuscitation priorities and fetal protection are managed as in standard trauma. Imaging is selected to avoid unnecessary exposure. The principle of maternal resuscitation first is unchanged, and the ATLS 11th edition covers trauma in pregnancy. ^[2]

Immunocompromise, bleeding tendency and coagulopathy. Early liaison with maxillofacial, vascular and oedodontic specialists and correction of coagulopathy are needed.

• Violation of the platysma defines a penetrating neck injury; vascular injury occurs in up to 25% and aerodigestive injury in 23-30%, with overall mortality of 3-6% and higher when the aerodigestive tract is involved. ^[1]
• Hard signs (expanding haematoma, severe or uncontrolled bleeding, shock not responding to fluids, absent pulse, bruit or thrill, cerebral ischaemia, airway compromise) mean operate; soft signs in a stable patient mean CT angiography and observation. ^[1]
• Permissive hypotension (around 90 mmHg systolic), direct pressure, haemostatic dressings, Foley catheter tamponade and avoidance of intubation hazards all support safe management. ^[1]
• ATLS 11th edition (2025) places control of exsanguinating haemorrhage first (xABCDE) with physiology-driven, balanced resuscitation, and prefers video laryngoscopy and modified rapid sequence induction with ketamine or etomidate. ^[2]
• Facial fractures are diagnosed by physical findings plus CT with 90% or greater sensitivity; plain films can miss many. ^[3]
• Cervical spine injury must be excluded first in all cranio-maxillofacial trauma, and the AO CMF approach keeps the primary repair window within two weeks. ^[7]
• Le Fort fractures threaten the airway (backward maxilla) and cosmesis; mortality rises from 0 to 8.7% with type. Avoid bite blocks. ^[3]
• Bilateral mandibular fractures can obstruct the airway (posterior tongue displacement) and are relieved by anterior traction; sublingual haematoma points to a mandibular fracture. ^[3]
• Orbital trauma is an emergency when compartment syndrome (decompress within 1-2 hours), trapdoor entrapment (release within 24-48 hours) or retrobulbar haematoma is present. ^[3][4]
• Nasal septal haematoma must be drained within 24 to 48 hours to prevent cartilage necrosis and saddle nose deformity. ^[3]
• Avulsed permanent teeth are replanted; success depends on storage in milk, saline or saliva and an extraoral dry time under 30 minutes. ^[5]
• Children have fewer facial fractures but paediatric trapdoor and white-eyed blow-out fractures, and airway anatomy that warrants earlier intervention. Older adults have low-energy falls, osteoporosis and anticoagulation. ^[3]

Penetrating trauma (secondary survey); Traumatic brain injury and skull fractures; Chest and thoracic trauma; Abdominal and pelvic trauma; Airway management and general anaesthesia; Shock and haemorrhage; Tetanus prophylaxis; Wound management and infection; Oral and neck infections; Eye emergencies; Burns; Pulmonary contusion; Compartment syndrome and open fractures. These are listed as plain text because not all corresponding pages are published in this build.