eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Fracture, Face

Author: Thomas Widell, MD, Vice Chairman, Assistant Professor, Department of Emergency Medicine, Rosalind Franklin School of Medicine/The Chicago Medical School, North Chicago, Illinois; Associate Residency Director, University of Chicago Emergency Medicine Program, Chicago, Illinois; Program Director Emergency Medical Education, Attending Physician, Mount Sinai Hospital Medical Center, Chicago, Illinois
Contributor Information and Disclosures

Updated: Mar 6, 2008

Introduction

Background

In approximately 400 BC, Hippocrates provided the first description of a variety of facial injuries. Rene Le Fort used cadaver studies in 1900 to provide detailed descriptions of 3 basic types of facial fracture.

Endotracheal anesthesia and radiography developed during the First World War led to better understanding and treatment of facial fractures. During the Second World War, a multidisciplinary approach to treatment of facial fractures continued to improve the outcomes of severely injured soldiers. The more recent introduction of CT reconstruction, along with new surgical techniques, has improved cosmetic results immensely.

Pathophysiology

Maxillofacial fractures result from blunt or penetrating trauma. Blunt injuries are far more common, including vehicular accidents, altercations, sports-related trauma, occupational injuries, and falls. Penetrating injuries include gunshot wounds, stabbings, and explosions.

Mass, density, and shape of the striking object, as well as speed of impact, directly affect type and severity of facial injury. The force required to fracture various facial bones may be classified as high impact (greater than 50 times force of gravity [g]) or low impact (less than 50 g).

• High impact
  • Supraorbital rim: 200 g
  • Symphysis mandible: 100 g
  • Frontal-glabellar: 100 g
  • Angle of mandible: 70 g
• Low impact
  • Zygoma: 50 g
  • Nasal bone: 30 g

Simple nasal fractures are the most common of all facial fractures. They must be distinguished from the more serious nasoethmoidal (NOE) fractures. NOE fractures extend into the nose through the ethmoid bones. Fractures through the ethmoid are prone to cerebrospinal fluid (CSF) leaks from dural tears.

Zygomatic arch fractures tend to occur in 2-3 places along the arch. Often 3 breaks occur, 1 at each end of the arch and a third in the middle, forming a V-shaped fracture; this often impinges on the temporalis muscle below, causing trismus.

Zygomaticomaxillary (tripod) fractures result from a direct blow to the cheek. Fracture occurs at articulations of the zygoma with the frontal bone maxillae and zygomatic arch and often extends through the orbital floor. Because the infraorbital nerve passes through the orbital floor, hypesthesia often occurs in its sensory distribution.

Alveolar fractures occur just above the level of the teeth through the alveolar portion of the maxilla. Usually a group of teeth is loose, and blood is noted at the gingival line.

Le Fort fractures

Le Fort or midface fractures are classified into 3 types and occasionally are mixed from one side of the face to the other.

• Le Fort I: Horizontal maxillary fracture separates the maxillary process (hard palate) from the rest of the maxilla. Fracture extends through the lower third of the septum and involves the maxillary sinus. This is below the level of the infraorbital nerve and thus does not cause hypesthesia.
• Le Fort II: Pyramidal fracture starts at the nasal bone, extends through the lacrimal bone, and courses downward through the zygomaticomaxillary suture. It courses posteriorly through the maxilla and below the zygoma into the upper pterygoid plates. The inner canthus of the nasal bridge is widened. Because the fracture extends through the zygoma, near the exit of the infraorbital nerve, hypesthesia often is present. Bilateral subcutaneous hematomas often are present.
• Le Fort III: Craniofacial dysjunction also starts at the nasal bridge. It extends posteriorly through the ethmoid bones and laterally through the orbits below the optic foramen, through the pterygomaxillary suture into the sphenopalatine fossa. This fracture separates facial bones from cranium, causing the face to appear long and flat (ie, dish face).

For more information, see Medscape's Trauma Resource Center.

Frequency

United States

Approximately 3 million facial injuries occur annually, but most do not involve maxillofacial fractures. One study placed the incidence of severe maxillofacial injury (fractures and lacerations) at 0.04-0.09% for motor vehicle collisions. Motor vehicle-related injuries are more common in rural areas, and altercation-related injuries are more frequent in inner cities.

Mortality/Morbidity

Incidence of other major injuries is as high as 50% in high-impact facial fractures, compared with 21% for low-impact fractures. Motor vehicle collision-related fractures are more likely to have associated injuries than violence-related fractures. The mortality rate is as high as 12% in high-impact fractures but is rarely due to maxillofacial injury. The incidence of associated cervical spine injuries has been reported in the 0.2-6% range.

Sex

Adult male-to-female ratio is 3:1. Suspect domestic violence or sexual assault in women as this may coexist in 30% of cases.

Age

Male predominance is reduced to 3:2 in children. Child abuse should be suspected, particularly in nonmotor vehicular injuries.

Clinical

History

• First priority is to perform a primary survey and attend to ABCs, as maxillofacial fractures are caused by significant trauma. Initially, focus on assessment of airway patency, breathing, circulation, and gross neurologic function, as well as control of the cervical spine.
• Once life-threatening issues are addressed, obtain a thorough history.
  • Allergies
  • Medications
  • Past medical history
  • Last meal
  • Events leading to injury
• Ask specific questions regarding injury.
  • What was the mechanism of injury?
  • Did the patient lose consciousness?
  • Has the patient had any visual problems such as double or blurred vision?
  • Has the patient had any hearing problems, such as decreased hearing or tinnitus?
  • Do teeth come together normally (normal occlusion)?
  • Is patient able to bite down without pain?
  • Does the patient have areas of numbness or tingling on the face?
  • In women, ask if the injury was from a partner or if they feel threatened by anyone.
  • In children, ask questions to determine if child abuse is an issue.

Physical

• Complete examination of the face is necessary, since multiple injuries easily occur. Portions of the examination specific for facial bones are marked with an asterisk (*).
  • Inspect face for asymmetry, which is often easiest to do looking down from the head of the bed.*
  • Inspect open wounds for foreign bodies and palpate for bony injury.*
  • Palpate the bony structures of the supraorbital ridge and frontal bone for step-off fractures.
  • Thoroughly examine eyes for injury, abnormality of ocular movements, and visual acuity.*
  • Inspect nares for telecanthus and widening of the nasal bridge, and palpate for tenderness and crepitus.*
  • Inspect nasal septum for septal hematoma and clear rhinorrhea, which may suggest a CSF leak.*
  • Palpate zygoma along its arch as well as its articulations with the frontal bone, temporal bone, and maxillae.*
  • Check facial stability by grasping teeth and hard palate and gently pushing back and forth, then up and down, feeling for movement or instability of midface.*
  • Inspect teeth for fracture and bleeding at the gum line (a sign of fracture through the alveolar bone), and test for stability.*
  • Check teeth for malocclusion and step-off.* Inspect for bleeding between teeth at the gum line (a sign of mandibular fracture).
  • Palpate mandible for tenderness, swelling, and step-off along its symphysis, body, angle, and condyle anterior to the ear canal.
  • Evaluate supraorbital, infraorbital*, inferior alveolar, and mental nerve distributions for hypesthesia or anesthesia.
• Nasal bone fracture: This is diagnosed by a history of trauma with swelling, tenderness, and crepitus over the nasal bridge. The patient may have had epistaxis that has resolved, but no clear fluid (CSF) should be present.
• NOE fracture: Suspect NOE if the patient has evidence of a nasal fracture with telecanthus, widening of the nasal bridge with detached medial canthus, and epistaxis or CSF rhinorrhea.
• Zygoma fracture: Physical findings of a depressed malar eminence with tenderness suggest a zygoma or zygomatic arch fracture. Often edema is marked, which can obscure the depression. The patient may complain of pain in the cheek on movement of the jaw. The patient may have trismus or difficulty opening the mouth from impingement of the temporalis muscle as it passes under the zygoma.
• Tripod fracture
  • Suspect tripod fracture after blunt force to the cheek with physical findings of marked periorbital edema and ecchymosis. Malar flattening may be seen early, but marked swelling of overlying tissues often obscures this finding. Lateral canthus may be depressed if the zygoma is displaced inferiorly. Hypesthesia of the infraorbital nerve often is present, because the fracture extends through the orbit into the zygomaticomaxillary area where the nerve exits.
  • Palpating the zygomaticomaxillary arch from inside the mouth may reveal a step-off fracture. A step-off may be noted at the zygomaticofrontal suture or on the zygomatic arch as well. Eye injuries may be associated with these fractures; thus, a thorough eye examination is important to document and act upon.
• Le Fort fractures
  • Le Fort I fractures: Physical findings include facial edema and mobility of the hard palate. This is evaluated by grasping the incisors and hard palate and gently pushing in and out.
  • Le Fort II fractures: Findings include marked facial edema with telecanthus, bilateral subconjunctival hemorrhages, and mobility of the maxilla. Epistaxis or CSF rhinorrhea may be noted.
  • Le Fort III fractures: Findings include the appearance of facial elongation and flattening (ie, dishface deformity). Maxilla often is displaced posteriorly, causing an anterior open bite. Grasping the teeth and hard palate and gently moving them results in movement of all facial bones in relation to the cranium. CSF rhinorrhea is almost always present but may be obscured by epistaxis.

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