Complications associated with facial trauma and their medicolegal implications 

Facial trauma occurs most commonly during road traffic accidents, falls, assaults and sports-related injuries. It is most likely to occur in men aged 20–40 years. As the bones of the face and skull protect the brain and major sensory organs, the consequences of facial trauma can be extremely serious. Although associated with significant levels of morbidity, facial trauma is generally not considered to be life-threatening in its own right, but it can give rise to complications that may result in the death of the patient. Less serious complications may still require prompt treatment to avoid irreversible damage.  

Airway obstruction is one of the most serious consequences of facial trauma. It may be apparent at the time of the injury, due to inhalation of a foreign body or narrowing of the airway following displacement of a fracture and any associated bleeding. However, it can also arise in the hours or days following the initial incident if soft tissue injury leads to significant swelling and oedema. It is therefore important that patients are monitored closely for any breathing difficulties. Undiagnosed cervical spinal injuries are also a major concern and in order to prevent irreversible neurological injury, it is probably safer to assume that the patient has sustained this type of injury until it is definitively ruled out. Cerebrospinal fluid leaks may lead to the development of meningitis but as presentation can be delayed, identification is not always straightforward.  

The majority of facial trauma incidents result in one or more fractured bones. Fractures in the eye socket can be associated with injuries to the eye itself, which if undiagnosed, can lead to sight loss. Although most cases of double vision resolve spontaneously, persistent cases can indicate misplaced or trapped soft tissue requiring further evaluation. Malposition of the lower eyelid is also common and requires careful retraction of the soft tissues in the periorbital region if it is to be avoided. Displacement of the eyeball occurs relatively frequently and can be particularly challenging to correct if it is associated with significant scarring in the area.  

While facial fractures are common, a failure to diagnose them can lead to later complications. For example, reconstruction of the nasal bones has a much lower success rate if delayed. If the healed bones are poorly aligned, breathing difficulties can arise. Fractures in the cheek bones can lead to asymmetry of the face and may even impact on the function of the eye. However, good repair in this area is difficult and the risk of complications is high.  

Fractures to the jaw occur in nearly 75% of all incidents of facial trauma. Inadequately treated fractures can lead to misalignment of the teeth, infection, delayed or abnormal bone healing and nerve damage. Healing can also be affected by the amount of movement this area is subjected to. Stresses across the fracture or the screws holding it together may lead to bone resorption, resulting in further instability. In the most severe cases, non-union of the bone may result. As well as potential disruption to the airway, jawbone fractures may lead to difficulties with eating and speaking. Many patients report pain and problems with chewing or swallowing, leading to dietary changes, several months after injury. There may be emotional effects too, with many patients reporting dissatisfaction with their newly restricted diet, psychological symptoms and poorer social functioning.  

The physical consequences of facial trauma, such as scarring and loss of functionality, are obvious but the psychological burden of this type of injury is less visible and may not be immediately apparent. However, the need for psychological assessment and treatment following facial trauma is becoming increasingly understood. Patients with facial injuries report increased levels of anxiety, depression, acute stress reaction, post-traumatic stress disorder and substance misuse, which can add a considerable additional burden to the physical consequences of their injuries. Not surprisingly, patients with significant post-injury deformities experience worse psychological outcomes, as do those who suffered extreme distress during the actual incident. However, there is no consistent relationship between the cause of the injury, whether assault, road traffic accident or workplace incident, and psychological outcome. Currently, there is no standardised practice for the psychological screening of facial trauma patients, and there is little evidence to suggest the optimum timing for such assessment. While assessment could take place in hospital, this approach would miss those who are not admitted as inpatients. Therefore, referral of patients to mental health services may be more effective if it is incorporated into outpatient appointments.  

Severe facial trauma can result in significant functional, aesthetic and psychological complications. As many patients are relatively young, the effects of this type of injury may be experienced for many decades. It is not only patients who experience a decreased quality of life: close family members are often affected too. As well as taking steps to improve the physical outcome of facial trauma, early psychological support is needed. Therefore, a holistic approachinvolving close collaboration between surgeons and providers of mental health services will give the best outcome for patients with facial trauma.