Facial fractures

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Facial fractures include fractures of the forehead, orbits, midface, and mandible. They are typically caused by high-energy blunt trauma related to sports, violent altercations, motor vehicle collisions, or falls. Facial fractures may be simple, involving a single bone (e.g., nasal bone fracture, zygomatic arch fractures), or complex, involving more than one bone (e.g., Le Fort fractures, zygomaticomaxillary complex fractures). Facial fractures can be further classified based on the number of fracture lines (simple or comminuted fractures), displacement, and soft tissue involvement (open fractures or closed fractures). Clinical features vary depending on the bones involved but usually include facial pain, bruising, palpable step-off, and mobile bone fragments. Initial management of facial fractures focuses on identifying and addressing life-threatening injuries. Complications of facial fractures include nasal and/or oropharyngeal bleeding, traumatic eye injury, cranial nerve deficits, traumatic brain injury (TBI), CSF leakage, sinus wall breach, dental injury, and facial disfiguration. Expectant management may be sufficient for simple fractures but surgery may be necessary for unstable fractures and fractures with associated complications.

For details on forehead and frontal bone fractures, see “Skull fractures.”

For details on orbital fractures, see “Traumatic eye injuries.”

Midfacial fractures

Other facial fractures

• Orbital fractures, e.g., orbital wall fractures
• Mandibular fractures

Initial approach ^[2][3]

Follow the advanced trauma life support (ATLS) algorithm and prioritize immediate stabilization of life-threatening injuries.

• Primary survey
  • Perform C-spine immobilization.
  • Anticipate the need for difficult airway management and invasive mechanical ventilation.
  • NIPPV is usually contraindicated in patients with facial injuries and deformities.
  • Begin hemostatic control for any significant nasal and/or oropharyngeal bleeding.
  • If signs of TBI are present, begin TBI management.
• Secondary survey (once the patient is stabilized)
  • Evaluate for facial contusions, swelling, tenderness, and deformities.
  • Assess for associated injuries, e.g., C-spine injury, skull fractures, ocular trauma, dental injuries
  • Obtain high-resolution CT face (see “Diagnostics for facial fractures”).
  • Perform further diagnostics (e.g., ocular examination, CSF detection studies, CT head and cervical spine) as needed.

Red flags for a difficult airway in patients with facial fractures include oropharyngeal bleeding, expanding hematomas, and/or significant distortion of the mouth, oropharynx, and/or upper neck. ^[2]

Supportive care ^[2]

• Perform acute wound management.
• Manage any dental injuries.
• Implement CSF leak precautions and consult neurosurgery for patients with suspected liquorrhea.
• Consider prophylactic antibiotics for facial injuries.
• Provide tetanus prophylaxis as indicated.

Prophylactic antibiotics for facial injuries ^[2][4]

Prophylactic antibiotics are not routinely recommended. Follow local protocols and specialist advice. ^[2][4]

• Indications
  • Open fractures (including any mandibular fracture with dental involvement)
  • Fractures breaching a sinus wall
  • Dental avulsion
  • Facial wounds: contaminated wounds, bite wounds, and in immunocompromised patients
• Regimens depend on the specific indication, e.g.:
  • Coverage of sinus and nasal pathogens for sinus wall fractures ^[5]
  • See also “Dental avulsion.”

Definitive management ^[2][6][7]

The following principles apply generally to facial fractures. For fracture-specific management: See “Nasal fractures,” “Zygomatic fractures,” and “Mandibular fracture.”

• Conservative management: for nondisplaced fractures without vascular or neurological complications
• Surgical management
  • Indications
    • Unstable fractures
    • Major facial deformity
    • Fractures with neurological, vascular, or ocular involvement
  • Procedures
    • Restoration of facial structures and proportions
    • Intraoperative adjustment of dental malocclusion
    • Open reduction or closed reduction with or without internal fixation

Disposition ^[2]

• Consult oromaxillofacial surgery for definitive management.
• Consider additional consults (e.g., ENT, ophthalmology, critical care) as needed.
• Admit patients requiring surgical intervention, airway management, or observation (e.g., for moderate TBI, severe TBI, or delayed intracranial hemorrhage)
• Consider discharge with close outpatient follow-up in patients with isolated facial fractures who have no associated injuries, signs of airway compromise, or evidence of moderate TBI or severe TBI.

Clinical evaluation ^[2][3]

• Physical examination: Assess for midfacial and mandibular instability, cranial nerve deficits, and concomitant orbital, nasal, and/or dental injuries.
• Ocular examination: indicated in Le Fort II, Le Fort III, and zygomaticomaxillary complex fractures to assess for ocular injury

Imaging ^[2][3]

• High-resolution CT face (preferred modality): thin slices and 3D reconstruction
  • To determine the type and number of midfacial and mandibular fractures
  • To evaluate for continuity of orbital boundaries, sinus injuries, and soft tissue involvement
• X-ray face (Waters or occipitomental view): if CT is not immediately available
  • May be used to rule out fractures in stable patients with low-moderate pretest probability of facial fracture
  • Follow-up CT is indicated if fractures or sinus air-fluid levels are detected.
• CTA head and neck: Consider in Le Fort II and Le Fort III fractures to screen for blunt cerebrovascular injury.
• Additional imaging: to assess for associated injuries
  • Consider based on clinical suspicion (e.g., ocular ultrasound, CT head, CT cervical spine).
  • See also “Diagnostics in head injuries” and “Traumatic eye injuries.”

Facial fractures are often caused by high-energy impacts. Maintain a low threshold for imaging the head and cervical spine to assess for associated injuries. ^[2]

Laboratory studies ^[2][3]

• Not routinely required.
• Consider CSF detection studies if there is discharge or bleeding from the nose and/or ears

Definition

• A skull fracture that involves the nasal bones, lacrimal bone, ethmoid, sphenoid, maxilla, zygomatic bone, and/or palatine bone

Epidemiology

• ♂ > ♀
• Peak incidence: age 20–30 years ^[8]
• The majority of midfacial fractures involve the nasal bone and the zygomatic bone.

Etiology ^[6][9]

High-energy impact to the midface, e.g., due to:

• Assault
• Falls
• Sports injury
• Motor vehicle collision
• Firearms
• See also “Le Fort fracture.”

Clinical features

See also “Clinical features” in “Nasal bone fractures” and “Zygomatic bone fractures.”

• Facial contusions, local swelling, and tenderness
• Facial asymmetry and midface instability of varying degree
• Palpable gap along the surface of the bone
• Subcutaneous emphysema in paranasal sinus fractures ^[10]

Complex midfacial maxillary fractures

The Le Fort classification is used to guide the management of complex midfacial fractures. Simple midfacial fractures (e.g., limited to the nasal, orbital, and/or ethmoid bones) are not captured in this system. ^[6]

Midfacial fractures can cause significant blood loss and/or airway compromise because of the rich blood supply and swelling potential of involved structures. ^[12]

Epidemiology ^[13]

• Most common type of facial bone fracture
• Adults: 5% of all facial fractures ^[14]
• Infants: 16% of all facial fractures ^[14]

Etiology ^[14]

• Motor vehicle crashes
• Physical violence (e.g., punches, elbowing)
• Sports-related injuries (e.g., soccer, basketball)

Clinical features ^[15]

See also “Classification” and “Clinical features” in “Midfacial fractures” for complex facial fractures involving the nasal bones.

• Epistaxis
• Swelling, ecchymosis, and/or tenderness of the nasal bridge
• Crepitus upon palpation
• Nasal deformity

The inability to breathe through one or both nares indicates nasal airway obstruction. ^[2]

Diagnostics ^[13][15]

See also “Diagnosis of facial fractures.”

• Physical examination
  • External examination
    • Inspect all facial bony structures.
    • Evaluate for epistaxis, CSF rhinorrhea, airway obstruction, and septal hematoma or deviation.
  • Internal examination (after swelling has resolved)
• CT head and/or high-resolution CT face ^[2][13]
  • Not indicated for isolated, uncomplicated nasal fractures
  • Indicated if other facial fractures and/or skull fractures are suspected and prior to surgical reduction

Some abnormalities may not be immediately apparent. Patients with uncomplicated isolated nasal injury should be reevaluated 3–5 days after the injury once the swelling has subsided. ^[2]

Treatment ^[13][15]

Initial management

See also “Approach to management of facial fractures” for patients with nonisolated nasal injury or multiple trauma.

• Head elevation
• Pain management
• Ice packs
• Epistaxis control with compression or, if necessary, anterior packing

Obtain urgent specialist consult for patients with nasal septal hematoma, CSF rhinorrhea, and/or abnormal extraocular movement examination.

Definitive treatment

• Conservative management: uncomplicated nasal fractures
  • Nondisplaced nasal fractures: no further treatment
  • Displaced nasal fractures: closed reduction and external fixation with a nasal splint
    • Indication: isolated, uncomplicated nasal fractures with nonsevere displacement
    • Timing: 5–10 days after injury
• Operative management: complicated nasal fractures
  • Fractures with severe displacement
  • Acute saddle nose deformity
  • Nasal septal hematoma or airway obstruction
  • Open fractures

Patients with isolated nasal injury, no septal hematoma or nasal airway obstruction, and controlled epistaxis may be discharged with close otolaryngology or plastic surgery follow-up after 3–5 days.

Complications

Nasal septal hematoma ^[13][15]

• Definition: a collection of blood around the nasal septal bone or cartilage with intact nasal mucosa
• Etiology: nasal or facial trauma
• Clinical features
  • Unilateral or bilateral obstruction of the nasal lumen with blood-filled mucosa
  • Absence of overt bleeding (due to intact nasal mucosa)
• Diagnostics: rhinoscopy showing unilateral or bilateral balloon-like bloody protrusion
• Treatment: immediate surgical drainage
• Complications
  • Infection
  • Septal perforation
  • Nasal deformities

Undiagnosed or improperly managed nasal septal hematomas may have severe consequences, such as infection, nasal septal perforation, and saddle nose deformity.

Other

• Nasal septal perforation secondary to nasal septal hematoma
• Saddle nose deformity
• Deviated nasal septum
• Nasal ventilation problems and snoring

Definitions ^[6]

• Zygomatic arch fracture: isolated fracture of the zygomatic arch
• Zygomaticomaxillary complex fracture: complex lateral midfacial fracture involving the zygomatic arch, inferior and lateral orbital rim, and the anterior and posterior maxillary sinus walls

Epidemiology

• ZMC fractures are common ^[16]

Etiology

• Sports-related injuries (e.g., direct impact with sporting equipment or players)
• Physical altercations (e.g., punch or elbow impact with the malar eminence)

Clinical features ^[6][17]

See also “Le Fort classification” for complex facial fractures involving the zygomatic bone.

• Contusion over zygomatic bone, local swelling, lacerations
• Asymmetry of the malar eminence, depression of the affected side
• Impaired mastication and/or trismus
• Subcutaneous emphysema (in paranasal sinus fractures) ^[10]
• Traumatic facial nerve palsy
• Orbital injury: See also “Orbital floor fractures” and “Orbital apex syndrome.”
  • Unilateral periorbital hematoma
  • Diplopia
  • Ophthalmoplegia
  • Enophthalmos
  • Anesthesia of the cheek and upper lip (due to infraorbital nerve injury)

Diagnostics ^[6][17]

See also “Diagnosis of facial fractures.”

• Physical examination
  • Evaluate zygomatic symmetry and stability.
  • Check for palpable bone gaps or crepitus, subcutaneous emphysema, trismus, and cranial nerve deficits.
• Ocular examination: Evaluate visual acuity and ocular movement to rule out extraocular muscle entrapment.
• High-resolution CT face (preferred modality)
  • Evaluate the type and number of fracture lines, and displacement and/or rotation of bone fragments.
  • Assess the orbital roof, orbital floor, and contour of the orbital boundaries.

Treatment ^[6][17]

See “Facial fracture management” for a general approach.

Conservative management

• Indications: nondisplaced or minimally displaced stable fractures
• interventions
  • Analgesia
  • Physical measures (cooling, decongesting nose drops) and functional relief (e.g., soft food)
  • Closed reduction of minimally displaced, uncomplicated fractures
  • Observation

Operative management

• Indications
  • Displaced or comminuted fractures
  • Zygomatic arch instability
  • Functional impairment (e.g., trismus, muscle entrapment, diplopia)
  • Facial deformity (e.g., orbital globe positioning, malar eminence asymmetry)
  • Orbital apex or orbital floor fracture
• Procedure: open reduction and internal fixation (e.g., with miniplates, screws) to restore function and malar symmetry

Consult maxillofacial surgery for all ZMC fractures and Le Fort fractures.

Etiology ^[2][7]

• Violent altercations (most common)
• Motor vehicle collision
• Falls

Clinical features ^[2][7]

• External or intraoral swelling, tenderness, lacerations, and/or hematomas
• Trismus and/or impaired mastication
• Dental injuries and/or malocclusion
• Hypoesthesia of the lower lip due to inferior alveolar nerve injury

Ecchymosis of the floor of the mouth is pathognomonic for mandibular fractures. ^[7]

Diagnostics ^[2][7]

See also “Diagnosis of facial fractures.”

• Physical examination
  • Evaluate externally for palpable bone gaps, crepitus, neurological deficits, and mobile bone fragments.
  • Examine intraorally for soft tissue and dental injuries.
  • Check for malocclusion.
  • Consider screening with tongue blade bite test (TBBT) to assist clinical judgement ^[18]
• Imaging
  • High-resolution CT face with 3D reconstruction (preferred modality)
  • X-ray has low sensitivity for mandibular fractures ^[19]

Maintain a low threshold for imaging the head and cervical spine to assess for associated injuries in patients with a mandibular fracture. ^[2][7]

Treatment ^[2][7][20]

See “Management of facial fractures” for the initial approach.

• BIlateral unstable mandible fracture (flail mandible): high risk of airway compromise; anticipate difficult airway management. ^[21]
• Conservative management
  • May be considered for non- or minimally-displaced fractures with no malocclusion
  • Options include:
    • Soft diet with close observation alone
    • Closed reduction with short-course maxillomandibular fixation
  • Consider prophylactic antibiotics for facial injuries for fractures involving tooth-bearing regions of the mandible. ^[20]
  • See also “Temporomandibular joint dysfunction.”
• Operative management
  • Usually required for fracture stabilization and restoration of normal occlusion
  • Procedure: open reduction and internal fixation

Consult maxillofacial surgery for all mandibular fractures.

Monitor patients with bilateral mandibular fractures for airway compromise.