Face Fracture Treatment & Management

  • Author: Thomas Widell, MD; Chief Editor: Steven C Dronen, MD, FAAEM   more...
 
Updated: Nov 17, 2011
 

Prehospital Care

  • ABCs are first priority. If necessary, hold airway open by chin lift or jaw thrust. Avoid nasotracheal route of intubation because of the risk of intracranial tube placement.
  • Place patient on a backboard and collar if cervical spine injury is suspected.
  • Treat hypoventilation with intubation and bag ventilation.
  • Control actively bleeding wounds with direct pressure.
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Emergency Department Care

  • ABCs take priority. Reassess airway frequently. Early intubation, before edema occurs, can make airway control much easier than waiting until a problem arises from obstruction. When intubation by oral route is impossible, perform cricothyroidotomy to secure airway.
  • Before using paralytics in an intubation, carefully evaluate the ability to manage the airway with a bag and mask or laryngeal airway. If unable to manage the airway, do not paralyze the patient. Fiber optic guides or bronchoscopic-guided intubation may be an option. If in doubt, prepare for a cricothyrotomy before attempting the airway with either sedation or paralytics.
  • Avoid the temptation to focus on the obvious facial deformity, thereby failing to perform a complete primary survey. Other life-threatening conditions need to be diagnosed rapidly and appropriate resuscitation undertaken. Follow this with a complete secondary survey.
  • Evaluation of facial fractures is part of the secondary survey.[7]
  • Once the cervical spine has been cleared allow the patient to sit with suction available to facilitate maintenance of the airway.
  • Epistaxis may require anterior nasal packing to control bleeding. Posterior packing occasionally may be needed.
  • Drain septal hematomas to avoid necrosis of septal cartilage.
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Consultations

  • Refer patients with facial fractures to an oral and maxillofacial surgeon, ear, nose, and throat (ENT) surgeon, or plastic surgeon who is experienced in care of these injuries.
  • Consult a neurosurgeon if a CSF leak is diagnosed or suspected.
  • Refer care of patients with multiple injuries to a surgeon with experience in trauma care. If a surgeon with trauma experience is not available, transfer patient to a higher-level trauma center.
  • The incidence of posttraumatic stress disorder is high in patients with facial injuries, and consultation with a psychiatrist should be considered.[14]
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Contributor Information and Disclosures
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

Disclosure: Nothing to disclose.

Specialty Editor Board

Francis Counselman, MD, FACEP  Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Tom Scaletta, MD  Chair, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine

Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM  Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. McGill J, Ling LJ, Taylor S. Facial trauma. In: Rosen P, ed. Diagnostic Radiology in Emergency Medicine. Mosby-Year Book; 1992:51-76.

  2. Hendler BH. Maxillofacial trauma. In: Rosen P, ed. Emergency Medicine Concepts and Clinical Practice. Mosby-Year Book; 1998:1093-1103.

  3. Smith RG. Maxillofacial injuries. In: Harwood-Nuss A, ed. The Clinical Practice of Emergency Medicine. Lippincott, Williams and Wilkins; 1991:337-343.

  4. Thomas, SH, Sheperd, SM. Maxillofacial injuries. In: Harwood- Nuss, ed. The Clinical Practice of Emergency Medicine. Lippincott, Williams & Wilkins; 1996:408-18.

  5. Hasan N, Colucciello SA. Maxillofacial trauma. In: Tintinalli JE, Gabor KD, Stapczynski SJ, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw-Hill Co Inc; 2004:chap 257, p1583-159.

  6. Sullivan WG. Trauma to the face. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. 2nd ed. Lippincott, Williams & Wilkins; 1996:242-269.

  7. McCay MP. Facial trauma. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen's Emergency Medicine, Concepts and Clinical Practice. Vol 1. 6th ed. Philadelphia, PA: Mosby; 2006:39, 382-398.

  8. Yamamoto K, Matsusue Y, Murakami K, Horita S, Sugiura T, Kirita T. Maxillofacial fractures in older patients. J Oral Maxillofac Surg. Aug 2011;69(8):2204-10. [Medline].

  9. Spoor TC, Ramocki JM, Kwito GM. Ocular trauma. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. Lippincott, Williams & Wilkins; 1996:225-241.

  10. Snell RS, Smith MS. The face, scalp, and mouth. In: Clinical Anatomy for Emergency Medicine. Mosby-Year Book; 1993:206-241.

  11. Magarakis M, Mundinger GS, Kelamis JA, Dorafshar AH, Bojovic B, Rodriguez ED. Ocular Injury, Visual Impairment, and Blindness Associated with Facial Fractures: A Systematic Literature Review. Plast Reconstr Surg. Sep 14 2011;[Medline].

  12. Hwang K, Kim DH. Analysis of zygomatic fractures. J Craniofac Surg. Jul 2011;22(4):1416-21. [Medline].

  13. Javadrashid R, Khatoonabad M, Shams N, Esmaeili F, Jabbari Khamnei H. Comparison of ultrasonography with computed tomography in the diagnosis of nasal bone fractures. Dentomaxillofac Radiol. Dec 2011;40(8):486-91. [Medline].

  14. Glynn SM, Asarnow JR, Asarnow R, et al. The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg. Jul 2003;61(7):785-92. [Medline].

 
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