eMedicine Specialties > Sports Medicine > Face and Head

Facial Fractures: Differential Diagnoses & Workup

Author: Timothy J Rupp, MD, FACEP, Associate Medical Director, Physicians Emergency Care Associates, Methodist Health System, Dallas, Texas; Staff Physician, Innovative Emergency Medicine, Frisco, Texas; Staff Physician, Department of Emergency Medicine, Children's Medical Center of Dallas, Dallas, Texas
Coauthor(s): Steven Karageanes, DO, Director, Primary Care Sports Medicine Fellowship, Director, Sports Medicine Education, Center for Orthopedics and Neuroscience; Department of Medical Education, Oakwood Healthcare System
Contributor Information and Disclosures

Updated: Mar 14, 2008

Differential Diagnoses

Cervical Spine Acute Bony Injuries
Cervical Spine Sprain/Strain Injuries
Concussion
Facial Soft Tissue Injuries
Nasal Fracture

Other Problems to Be Considered

Basilar skull fracture
Closed head injury
Corneal abrasion /laceration
Dental fracture/avulsion
Globe rupture
Nasal septal hematoma

Workup

Laboratory Studies

  • Consider ordering preoperative laboratory studies, such as a complete blood cell (CBC) count, prothrombin time/active partial thromboplastin time (PT/aPTT), and blood type and crossmatch, for the consulting surgeon.

Imaging Studies

  • Generally, computed tomography (CT) scanning is the study of choice when evaluating facial fractures.
  • Frontal sinus fractures: Plain posteroanterior, lateral, and Waters radiographic projections demonstrate the fracture, whereas a CT scan with a thin 2-mm cut through the sinuses demonstrates the anatomy, the integrity of the posterior wall, and any pneumocephali that are pathognomonic for a posterior wall fracture.
  • Orbital fractures: Facial CT scanning in the axial and coronal planes with thin cuts through the orbits is the study of choice. Herniation of the orbital contents into the maxillary sinus, observed as clouding of the maxillary sinuses on plain radiographs, suggests an orbital floor fracture.
  • Nasal fractures: Radiographs are not usually necessary to diagnose this injury. However, plain nasal radiographs that consist of a lateral view that cones down on the nose and a Waters view can confirm the diagnosis. If a nasoorbitoethmoid fracture is suspected, facial CT scanning confirms the diagnosis.
  • Zygomatic/zygomaticomaxillary fractures: If a fracture is suspected, a facial CT scan with coronal and axial cuts elucidates the injury. A plain Waters view may be used as a scout radiograph.
  • Maxillary (Le Fort) fractures: These fractures are very difficult to assess with plain radiography. If the clinical examination findings are equivocal, then a plain Waters image may provide additional information; otherwise, facial CT scanning with coronal and axial cuts is the criterion standard.
  • Mandibular fractures: The study of choice is panoramic radiography. If this study is not available, then a mandibular series consisting of a right and left lateral oblique, posteroanterior, and Towne view may be obtained. Fractures of the condyle may require coronal plane CT scanning.

Other Tests

  • CSF rhinorrhea
    • Two methods exist to determine if CSF is present in nasal or ear secretions. The first involves placing a drop of the nasal fluid onto filter paper or a bed sheet. The CSF migrates farther than blood, forming a target shape with blood in the center and blood-tinged CSF on the outer ring.
    • An additional way to delineate CSF is by checking the glucose content of the nasal fluid as compared to the patient's serum. CSF generally contains 60% of the glucose of serum, and nasal mucus contains none. Keep in mind that neither of these tests is sensitive or specific.
  • Foreign-body aspiration: Chest radiography may assist in detecting aspiration of a foreign body.
  • Spinal injuries: A C-spine series detects any bony injuries to the cervical spine.

Procedures

  • Nasal packing
    • If the mid face is stable, the nares can be treated with drops of a vasoconstrictor (eg, Afrin) and packed with gauze.
    • If the mid face is unstable, this method does not work. Instead, insert a Foley catheter into the nares and inflate the balloon with air. Gently pull the balloon back to close off the posterior choanae. Then, pack the nasal chamber with gauze.
  • Lateral canthotomy: Lateral canthotomy can help relieve intraocular pressure if the physical examination reveals a proptotic and tense globe, which is suggestive of a retrobulbar hematoma. Using local anesthetic, an incision is made on the lateral canthus between the upper and lower eyelid to the orbital bone.
  • Temporomandibular joint reduction: The mandible dislocates forward and superiorly. Reduction is performed by placing gauze-covered thumbs on the third molars of the mandible with the fingers curled under the symphysis of the mandible. Then, downward pressure is exerted on the molars, with slight upward pressure on the symphysis to lever the condyles downward. A relaxant (eg, diazepam) may be useful if the muscle spasms. If the injury is trauma related, obtain a radiograph to rule out the presence of a fracture.

More on Facial Fractures

Overview: Facial Fractures
Differential Diagnoses & Workup: Facial Fractures
Treatment & Medication: Facial Fractures
Follow-up: Facial Fractures
Multimedia: Facial Fractures
References
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References

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Further Reading

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Keywords

maxillofacial fractures, tripod fractures, tetrapod fractures, blow-in fractures, blow-out fractures, blow out fractures, broken jaw, broken cheek, broken nose, Le Fort fracture, LeFort fracture, face fracture, nasal fracture, nasal bone fracture, orbital fracture, orbital floor fracture, orbital wall fracture

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Contributor Information and Disclosures

Author

Timothy J Rupp, MD, FACEP, Associate Medical Director, Physicians Emergency Care Associates, Methodist Health System, Dallas, Texas; Staff Physician, Innovative Emergency Medicine, Frisco, Texas; Staff Physician, Department of Emergency Medicine, Children's Medical Center of Dallas, Dallas, Texas
Timothy J Rupp, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, Gay and Lesbian Medical Association, Society for Academic Emergency Medicine, and Texas Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Steven Karageanes, DO, Director, Primary Care Sports Medicine Fellowship, Director, Sports Medicine Education, Center for Orthopedics and Neuroscience; Department of Medical Education, Oakwood Healthcare System
Steven Karageanes, DO is a member of the following medical societies: American Medical Association, American Osteopathic Association, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Gerard A Malanga, MD, Founder and Director, New Jersey Sports Medicine Institute; Director of Pain Management, Overlook Hospital; Director of Sports Medicine, Sports Medicine Fellowship Director, Mountainside Hospital; Clinical Chief, Rehabilitation Medicine and Electrodiagnosis, St Michael's Medical Center; Medical Director, Consultant, Horizon Healthcare Worker's Compensation Services, Blue Cross and Blue Shield Worker's Compensation
Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine, North American Spine Society, and Physiatric Association of Spine, Sports and Occupational Rehabilitation
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Henry T Goitz, MD, Chief, Sports Medicine, Associate Professor, Department of Orthopaedic Surgery, Medical College of Ohio
Henry T Goitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

Jon B Whitehurst, MD, Clinical Instructor of Surgery, University of Illinois College of Medicine; Partner and Executive Board Member, Rockford Orthopedic Associates; Orthopedic Chairman, Rockford Memorial Hospital
Jon B Whitehurst, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, and Arthroscopy Association of North America
Disclosure: Nothing to disclose.

Chief Editor

Craig C Young, MD, Professor, Departments of Orthopedic Surgery and Community and Family Medicine, Medical Director of Sports Medicine, Sports Medicine Fellowship Director, Medical College of Wisconsin
Craig C Young, MD is a member of the following medical societies: American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, Phi Beta Kappa, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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