eMedicine Specialties > Sports Medicine > Face and Head

Facial Fractures

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
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

Updated: Mar 14, 2008

Introduction

Background

Facial fractures  occur for a variety of reasons related to sports participation: contact between players (eg, a head, fist, elbow); contact with equipment (eg, balls, pucks, handlebars); or contact with the environment, obstacles, or a playing surface (eg, wrestling mat, gymnastic equipment, goalposts, trees). Although most sports-related facial injuries are minor, the potential for serious damage exists. A physician examining these injuries must rapidly assess the patient in a consistent and methodical manner, allowing for prompt diagnosis and appropriate treatment, while considering the physical demands of the sport, as well as the athlete's return to play.

Facial fractures may be associated with head and cervical spine injuries.^1,2 A review by Boden et al of catastrophic injuries associated with high school and college baseball demonstrated 1.95 direct catastrophic injuries annually, including severe head injuries, cervical injuries, and associated facial fractures.²

Fractures of the facial bones require a significant amount of force. The physician must take into account the mechanism of the injury as well as the physical examination findings when assessing the patient.

Forces that are required to produce a fracture of the facial bones are as follows:

• Nasal fracture – 30 g
• Zygoma fractures – 50 g
• Mandibular (angle) fractures – 70 g
• Frontal region fractures – 80 g
• Maxillary (midline) fractures – 100 g
• Mandibular (midline) fractures  – 100 g
• Supraorbital rim fractures – 200 g

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center; Breaks, Fractures, and Dislocations Center; Sports Injury Center; Eye and Vision Center; and Teeth and Mouth Center.

Also, see eMedicine's patient education articles Facial Fracture, Broken Nose, Broken Jaw, Concussion, Black Eye, and Broken or Knocked-out Teeth.

Related eMedicine topics:
Cervical Spine Sprain/Strain Injuries
Facial Trauma, Maxillary and Le Fort Fractures
Facial Trauma, Sports-Related Injuries

Related Medscape topics:
Resource Center Adolescent Medicine
Resource Center Exercise and Sports Medicine
Resource Center Trauma

Frequency

United States

Schulz noted that athletic injuries account for 11% of all facial fractures, and that facial injuries occur in 2% of all athletes.³

In another report, Laskin stated that 250,000 individuals, many of whom were children, experience facial trauma while engaged in athletic activities.⁴ Additionally, more than 100,000 sport-related injuries could be prevented by wearing appropriate head and face protection.

A review of facial fractures sustained by athletes during sports participation noted that in the medical literature, sporting activities account for 3-29% of facial injuries and 10-42% of all facial fractures.⁵ Tanaka and colleagues showed that 10.4% of all maxillofacial fractures are related to sports.⁶

Nearly 75% of facial fractures occur in the mandible, zygoma, and nose.⁷ Sports participation is the most common cause of mandibular fractures (31.5%), followed closely by motor vehicle accidents (27.2%). A study of facial fractures sustained during recreational baseball and softball demonstrated that the zygoma or zygomatic arch was the most common fracture subtype, followed by temporoparietal skull fractures and orbital blow-out fractures.⁸ A number of studies in the medical literature, however, indicate that the nasal bones are the most commonly fractured bones in the face, but because many of these patients do not seek medical treatment or the injuries are managed in the outpatient setting, the statistics may not reflect this trend.¹ It is likely that the nasal bones are more commonly fractured because of the lesser degree of force that is required to fracture the bone.⁹

Fractures of the orbit occur more commonly in young adult and adolescent males: the mean age for adult males is 32 years; the mean age for children, 12.5 years, and the majority of orbital fractures occur in boys. In addition to sports-related injuries, injuries sustained in motor vehicle collisions, assaults, and occupational injuries account for the majority of orbital fractures.¹⁰

Functional Anatomy

• Frontal sinus: Both the anterior and posterior wall may be damaged. Because the posterior wall is adjacent to the dura mater, damage in this region could result in central nervous system (CNS) complications such as a cerebrospinal fluid (CSF) leak or meningitis.
• Orbital: The bony orbit is composed of 7 bones of varying thickness. The frontal bone forms the supraorbital rim and orbital roof. The medial surface consists of the ethmoid, whereas the greater wing of the sphenoid and the zygoma create the lateral margin. Inferiorly, the floor and infraorbital rim are formed by the zygoma and maxilla. This portion is very thin; therefore, it is the most common site of fracture within the orbit. Fracture of the orbital floor, also known as a blow-out fracture, can result in entrapment of the inferior rectus muscle, limiting upward gaze (see Image 1). 
  • The most common fracture to the orbital rim involves the orbital zygomatic region; this fracture, which typically results from a high-impact blow to the lateral orbit, often results in a fracture to the orbital floor as well.¹⁰  
• Nasal: Nasal bone fractures are the most common of all facial fractures. The upper third of the nose is supported by the paired nasal bones and the frontal process of the maxilla, whereas the lower two thirds of the nose are maintained by cartilaginous structures.⁹ A more serious injury, a nasoorbitoethmoid fracture, occurs with trauma to the bridge of the nose. This injury involves extension into the frontal and maxillary bones and can result in disruption of the cribriform plate with concomitant CSF rhinorrhea.
• Zygomatic/zygomaticomaxillary complex: The zygoma, like the nasal bones, is a prominent facial bone and, therefore, is prone to injury. Commonly, a breakage in this area involves a central depression with fractures at both ends. The central fragment may impinge upon the temporalis muscles, resulting in trismus. Because of its thickness, isolated fractures of the zygoma are rare, often involving extension into the thinner bones of the orbit or maxilla, otherwise known as zygomaticomaxillary (ie, tetrapod or tripod fractures).
• Maxillary (Le Fort): Rene Le Fort first described fractures of the maxillary region in the 1900s (see Image 2).
  • Le Fort I injuries involve a transverse fracture of the maxilla above the level of the root apices and through or below the level of the nose.
  • Le Fort II injuries traverse the nose, infraorbital rim, and orbital floor and then proceed laterally through the lateral buttress and posteriorly through the pterygomaxillary buttress.
  • Le Fort III injuries, also known as craniofacial dysjunction, result from motor vehicle or motorcycle accidents and are the result of the mid face being separated from the cranial base.
• Mandibular: Fractures of the mandible can involve the symphysis, body, angle, ramus, condyle, and subcondyle regions. Generally, motor vehicle accidents result in fractures of the condylar and symphysis regions because the force is directed against the chin, whereas injuries from boxing are more likely to be located in the mandibular angle, as the result of a right-handed punch (see Image 3).

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Orbit Anatomy

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Sport-Specific Biomechanics

In general, facial fractures in athletic activities result from direct trauma over a small surface area. Sports that present a higher risk are those that involve small objects that are propelled at high velocity, such as baseball, softball, hockey, lacrosse, jai alai, and racquetball. Athletes who participate in sports with high levels of physical contact and collision are at risk as well; these sports include football, basketball, rugby, hockey, martial arts, and boxing.

Many of these sports have safety measures to limit the incidence of facial injuries, and attention should be paid to the rules of use. Racquetball players should always play with goggles to limit orbital blow-out injuries. In hockey, face guards with helmets are required in lower levels of play but not at the professional level. High school football players should all have mouthpieces fitted for them, and mouthpieces should be worn in place before every play.

An athlete's vision should be checked as part of a preparticipation physical examination yearly. Visual risk factors include a corrected visual acuity of 20/40 or less or spectacle correction greater than 6 diopters (D). These athletes need an ophthalmologist's evaluation before competing in sports.

A one-eyed athlete is defined as one with a visual acuity in one eye of 20/200 or less. These athletes may be able to participate with proper protection, and an ophthalmologist's evaluation is essential.

Related eMedicine topic:
Sports Physicals

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Clinical

History

Injuries to the head and neck frequently involve the airway or major vessels. The initial assessment, therefore, should begin with airway, breathing, and circulation (ABCs).

First, protect the airway by removing any foreign bodies and by placing the patient in a sitting position or on the side to facilitate expectoration of blood. If severe maxillofacial trauma is present, the athlete is at risk for airway obstruction because of a lack of tongue support from the mandibular structures. Consider placing an oral airway or, if necessary, performing endotracheal intubation. Second, assess the athlete for breathing and circulation. Lastly, evaluate the cervical spine. In the literature, cervical spine injuries have been shown to be present in 1-4% of patients with facial fractures. Because of the force necessary to fracture the facial bones, one should consider the cervical spine is fractured until proven otherwise, and cervical spine immobilization should be maintained.

Following initial stabilization of the ABCs, the examiner should proceed with the history and physical examination. The patient should be questioned regarding the mechanism of the injury, the presence of numbness or pain over any parts of the face, and visual disturbances. Specific questions regarding specific fractures of the face include the following:

• Frontal sinus fractures
  • This injury results from a severe blow to the frontal or supraorbital region, which can result in fracture of the anterior and/or posterior wall.
  • The patient may report numbness in the distribution of the supraorbital nerve.
• Orbital fractures
  • Blow-out fractures generally occur with blunt trauma to the orbit with an object larger in diameter than the orbital entrance (eg, baseball, fist).
  • A blow-in fracture results when a fracture fragment is displaced into the orbit, resulting in decreased orbital volume and impingement on orbital soft tissues, such as from high-velocity trauma (eg, falls from a height, severe blows to the orbit with a weapon).
  • Patients may report diplopia.
• Nasal fractures: With the exception of nasoorbitoethmoid fractures, nasal fractures are typically diagnosed based upon the history and physical examination findings. Often a history of a blow to the nose and epistaxis is present.
• Zygomatic/zygomaticomaxillary complex fractures
  • The athlete may report a forceful blow to the cheek with a bat or an elbow.
  • Fractures of the zygomaticomaxillary complex may result in trismus or numbness in the distribution of the infraorbital nerve.
• Maxillary (Le Fort) fractures
  • Le Fort I is a transverse fracture of the maxilla just above the teeth.
  • Le Fort II is a pyramid fracture of the maxilla, the apex of which is above the bridge of the nose and which extends laterally and inferiorly through the infraorbital rims.
  • Le Fort III is a complete craniofacial disruption and involves fractures of the zygoma, infraorbital rims, and maxilla. This injury requires a significant causative force and, therefore, is relatively uncommon in athletes; however, it may be observed with an injury from a hockey puck, baseball pitch, or baseball bat. Athletes with this injury may report diplopia, malocclusion, or numbness.
• Mandibular fractures: The patient may report malocclusion and jaw pain or numbness.

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Physical

The physical examination should be performed in a methodic, sequential manner. One approach organizes the examination from inside out and bottom up and involves inspection, palpation, and sensory and motor testing.

Examine the oral pharynx for lacerations, tooth fragments, or other foreign bodies. Look closely at the dentition to assess for tooth avulsion or tooth mobility, which can indicate underlying skeletal fractures. Then, carefully evaluate each region of the face, including the mandibular, maxillary, zygomal, nasal, orbital, and frontal bones.

Any areas of obvious trauma, such as a laceration, swelling, depression, or ecchymosis, should be examined more closely. Evaluate the mandible for trismus and mobility. The mid face should be assessed for stability and depression of the bones.

After inspection and palpation, test the motor and sensory function of the facial nerves and muscles. Hypoesthesia in the region of the infraorbital or supraorbital nerve may suggest an orbital fracture, whereas decreased sensation of the chin may result from inferior alveolar nerve compression from a mandibular fracture. Trismus, spasm of the muscles of the jaw, which results in the inability to open and close the mouth, can be secondary to mandibular or zygomatic fractures.

Any fluid from the nose should be inspected for possible CSF rhinorrhea, indicating disruption of the anterior cranial base. Lastly, examine the eyes, including the pupils, extraocular movements, visual acuity, and, if clinically indicated, intraocular pressure and corneal fluorescein. Findings for specific fractures include the following:

• Frontal sinus fractures
  • Look for a visible or palpable depression in the region of the frontal sinus.
  • A fracture of the posterior wall implies fracture of the dura and may be manifested by CNS depression, CSF rhinorrhea, or visible brain matter.
• Orbital fractures: Patients with orbital fractures may present with ecchymosis and edema of the eyelids, subconjunctival hemorrhage, diplopia with limitation in upgaze or downgaze, enophthalmos, infraorbital nerve anesthesia, or emphysema of the orbits/eyelids.
• One of the significant clinical features of a fracture to the orbital floor is entrapment of the inferior rectus muscle, resulting in impaired upward gaze on the affected side.  Entrapment of the inferior orbital nerve may result from a fracture of the orbital floor and is manifested by decreased sensation to the cheek, upper lip, and upper gingival region on the affected side.
  • Entrapment of these structures may be more commonly encountered in children, whose bones may be more flexible and demonstrate a linear pattern that snaps back to create a "trap-door" fracture; in adults, the floor of the orbit is thinner and more likely to shatter completely. Other features commonly encountered with fractures of the orbit include enophthalmos, in which the eye appears to recede into the orbit, and orbital dystopia, in which the eye on the affected side appears lower in the horizontal plane relative to the unaffected side.¹⁰
• Nasal fractures
  • Evidence of a nasal fracture includes epistaxis, swelling, tenderness, deformity, crepitus, nasal airway obstruction, and periorbital ecchymosis.
  • Always evaluate for septal deviation or septal hematoma. A bulging, bluish, tender septal mass requires evacuation. Failure to do so can result in necrosis of the nasal septum. Widening of the intercanthal distance suggests the possibility of a nasoorbitoethmoid fracture.
• Zygomatic/zygomaticomaxillary complex fractures
  • Impingement of the temporalis muscle may result in trismus, although this is only occasionally observed.
  • Depression of the inferior orbital rim, paresthesia in the distribution of the infraorbital nerve, or diplopia suggests extension into the orbit or maxilla.
• Maxillary (Le Fort) fractures: Physical examination findings include facial distortion in the form of an elongated face, a mobile maxilla, or mid-face instability and malocclusion.
• Mandibular fractures
  • In a report, Schwab et al looked at physical examination characteristics that predicted a mandibular fracture. The tongue blade test assesses the ability of patients to grasp a tongue depressor in between the teeth and patients' ability to hold the blade against mild resistance by the examiner on each hemimandible.¹¹
  • Inability to hold the tongue depressor had a negative predictive value of 96%, whereas malocclusion had an NPV of 87%; facial asymmetry, 76%; and trismus, 75%.¹¹

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.

Treatment

Acute Phase

Medical Issues/Complications

• Frontal fracture: Repair of the anterior wall may be delayed, but posterior wall fractures require immediate neurosurgical evaluation. The decision regarding whether prophylaxis with antibiotics is needed should be left to the consulting surgeon.
• Orbital fracture: The initial treatment is generally supportive, including head elevation, ice, and analgesics. The indications for surgical repair are controversial and may include diplopia that persists 2 weeks after the injury, large fractures, and enophthalmos. Orbital fractures that result in inferior rectus muscle entrapment, inferior orbital nerve entrapment, enophthalmus, or orbital dystopia may result in both cosmetic and functional impairment and should be referred to a specialist (ie, ophthalmologist, oral-maxillofacial surgeon, or plastic surgeon) within 24 hours to insure prompt resolution.¹⁰
• Nasal fracture: An angulated nasal fracture can be reduced by exerting firm, quick pressure with the thumbs toward the midline or by inserting a soft probe in the nares to elevate the depressed or deviated septum into anatomic position.⁵ Ongoing management of these injuries consists of control of epistaxis and supportive care with analgesics. Operative repair is best performed early, within 1-2 hours following the injury, or in 10-14 days following the injury once the swelling and edema has receded. Any open wounds require antibiotics.
• Zygomatic/zygomaticomaxillary fracture: Open reduction and internal fixation to restore the normal contour is the standard of care.
• Maxillary (Le Fort) fracture: Open reduction with internal fixation is the standard. If CSF rhinorrhea is present, a neurosurgeon should be consulted. Prophylactic antibiotics are warranted if the fracture extends through the tooth-bearing region or through the nasal or sinus mucosa.
• Mandibular fracture: Most cases require admission with fixation. These fractures often require antibiotics because of their location in the tooth-bearing region. Penicillin or clindamycin are acceptable choices.

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Consultations

Once a fracture has been identified, an appropriate surgeon or specialist (ie, plastic surgeon; ophthalmologist; ear, nose, and throat specialist; oral-maxillofacial surgeon; or neurosurgeon) provides the definitive care.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained injuries.

Related Medscape topics:
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Resource Center Pain Management: Pharmacologic Approaches

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

400 mg PO q4h or 800 mg PO q8h; not to exceed 2400 mg qd

Pediatric

4-10 mg/kg PO q6-8h prn; not to exceed 50 mg/kg/d

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; aspirin/NSAID-induced asthma; third trimester of pregnancy

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in patients with congestive heart failure, nasal polyps, hypertension, and decreased renal and hepatic function, and in elderly patients; caution in the presence of coagulation abnormalities or during anticoagulant therapy

Acetaminophen (Feverall, Tylenol, Aspirin Free Anacin)

DOC for pain in patients with a documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking PO anticoagulants.

Dosing

Adult

325-1000 mg PO/PR q4-6h; not to exceed 4 g/d

Pediatric

10-15 mg/kg PO/PR q6-8h prn; not to exceed (if >12 y) 4 g/d

Interactions

Alcohol, barbiturates, carbamazepine, INH, and phenytoin increase the risk of hepatotoxicity; rifampin decreases acetaminophen efficacy; acetaminophen doses >2 g/d may potentiate the warfarin effect and increase INR

Contraindications

Documented hypersensitivity; known G6PD

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity is possible in people with long-term alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; acetaminophen is contained in many OTC products, and combined use with these products may result in cumulative acetaminophen doses that exceed the recommended maximum dose

Acetaminophen and hydrocodone (Lortab, Norcet, Vicodin, Lorcet HD)

Drug combination indicated for moderate to severe pain.

Dosing

Adult

1-2 tab PO q4-6h prn; not to exceed 8 tab/d

Pediatric

500/7.5 per 15 mL, 0.6 mg/kg/d PO divided q6-8h; not to exceed 1.25 mg/dose if <2 y, 5 mg/dose if 2-12 y, 10 mg/dose if >12 y

Interactions

Alcohol and INH increase the risk of hepatotoxicity; anticholinergics and antidiarrheals combination increase the risk of severe constipation; CNS depressants increase the risk of CNS depression; MAOIs increase the risk of severe hypertension; TCAs in combination increases the concentration of both drugs

Contraindications

Documented hypersensitivity; depressed respiratory function; increased ICP; acute abdominal pain; pseudomembranous colitis; toxin-related diarrhea; impaired liver function

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

The tablets contain metabisulfite, which may cause hypersensitivity; caution in patients who are dependent on opiates because this substitution may result in acute opiate withdrawal symptoms; caution in the presence of severe renal or hepatic dysfunction

Aspirin and oxycodone (Percodan, Roxiprin, Codoxy)

Drug combination indicated for the relief of moderate to severe pain.

Dosing

Adult

1 tab or cap PO q6h

Pediatric

Not established

Interactions

Phenothiazines may decrease the analgesic effects; conversely, toxicity increases when administered concurrently with CNS depressants or tricyclic antidepressants; may also potentiate the anticoagulant effects of warfarin

Contraindications

Documented hypersensitivity; liver damage; hypoprothrombinemia; vitamin K deficiency; bleeding disorders; asthma; use in children who have the flu and are <16 y (due to the association of aspirin with Reye syndrome)

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Duration of action may increase in elderly patients; caution in the presence of renal or liver impairment, peptic ulcer disease, and erosive gastritis

Ketorolac (Toradol)

Inhibits prostaglandin synthesis by decreasing the activity of the enzyme cyclooxygenase, which results in decreased formation of prostaglandin precursors.

Dosing

Adult

30 mg IV/IM q6h; not to exceed 120 mg/d

10 mg PO q4-6h; not to exceed 40 mg/d

Combined duration of PO/IV/IM not to exceed 5 d

Pediatric

Not established

Interactions

Coadministration with aspirin increases the risk of inducing serious NSAID-related adverse effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; may increase PT duration when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; administration into CNS

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases the risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts (rare) usually return to normal during ongoing therapy; discontinue therapy if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs

Morphine (Duramorph, Astramorph, MS Contin)

DOC for analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone.

Various IV doses are used; commonly titrated until desired effect is obtained.

Dosing

Adult

10 mg IM/SC q4h prn

Alternatively, 10-30 mg PO q4h or 10-20 mg PR q4h

Pediatric

0.2-0.5 mg/kg PO/PR q4-6h
Alternatively, 0.1-0.2 mg/kg IV/IM/SC q2-4h; not to exceed 15 mg/dose

Interactions

Anticholinergics increase the risk of severe constipation; buprenorphine blocks the effects of morphine; precipitates withdrawal; cimetidine increases the effects of morphine; CNS depressants increase the risk of CNS depression; MAOIs combination increases the risk of hypotension and respiratory depression; rifampin decreases morphine concentrations; morphine may increase the serum levels of zidovudine

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in patients with hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial flutter, and other supraventricular tachycardias; has vagolytic action and may increase the ventricular response rate

Antiemetics

Antiemetics are useful in the treatment of symptomatic nausea.

Promethazine (Phenergan, Anergan, Prorex, Phenazine)

Anti-dopaminergic agent that is effective in treating emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in the brain and reduces stimuli to the brainstem reticular system.

Dosing

Adult

12.5-25 mg PO/IM q4-6h prn

Pediatric

<2 years: Contraindicated

0.25-1 mg/kg PO/IM/PR q4-6h prn; not to exceed 25 mg/dose

Interactions

May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension

Contraindications

Documented hypersensitivity; glaucoma, narrow-angle; lactation; children younger than 2 y (incidences of death due to respiratory depression)

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in the presence of impaired liver function, elderly patients, seizure disorder, and asthma

Ondansetron (Zofran)

Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally. Prevents nausea and vomiting associated with emetogenic cancer chemotherapy (eg, high-dose cisplatin) and complete body radiotherapy.

Dosing

Adult

4 mg/dose IV

Alternatively, 0.15 mg/kg/dose PO

Pediatric

Not established

Interactions

Although cytochrome P-450 inducers (eg, barbiturates, rifampin, carbamazepine, phenytoin) can potentially change the half-life and clearance of ondansetron, a dosage adjustment is not usually required

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Medication is to be administered for prevention of nausea and vomiting, not for rescue of nausea and vomiting

Follow-up

Return to Play

In fractures that involve or approximate the eye, visual acuity is the most important factor in return to play. Any unexplained loss of acuity needs a complete workup. The aforementioned 20/40 criteria to play still apply (see Sport-Specific Biomechanics). Any athlete returning to competition without complete bone healing needs adequate protection, such as a full face shield, modified batting helmets, extended hockey eye visors, or larger football face masks.

Athletes need to regain their confidence in returning to play. An athlete who has physically recovered may not be mentally recovered from the trauma of the injury and, thus, is at risk of further injury. This is often observed in baseball players hit in the face by a pitch or hit ball. Psychologic recovery from facial fractures can be assessed in controlled practice situations. A consultation with a sports psychologist may be necessary if difficulties linger.

Return-to-play recommendations are not affected after orofacial fractures.¹² In a report by Laskin, the author observed that more than 100,000 sport-related injuries could be prevented annually by wearing appropriate head and face protection.⁴

Related Medscape topics:
Resource Center Adolescent Medicine
Resource Center Exercise and Sports Medicine
Resource Center Trauma

Prevention

Adherence to the rules and guidelines established by the specific sports governing body is most important. Almost all eye injuries are preventable, but other fractures can and do occur in sports with high levels of physical contact. Visual acuity, protective gear, and adherence to the rules of the sport are the best ways to limit the risk of facial fractures.

Education

Miscellaneous

Medicolegal Pitfalls

• Airway management in patients with facial injuries should be aggressive. Subsequent bleeding and edema can result in airway obstruction. This should be taken into account, especially if a patient requires transfer. CT scans are the studies of choice. If the clinical suspicion for airway obstruction is high and plain radiographs are negative, then a CT scan should be obtained.
• CNS and ophthalmologic injuries can have dire consequences if missed or detected too late. Perform thorough neurologic and eye examinations and consult specialists early.

Related Medscape topics:
Resource Center Medical Malpractice and Legal Issues
Resource Center Resuscitation
Resource Center Trauma

Multimedia

Media file 1: The bony walls of the orbit.

Media file 2: Le Fort fractures.

Media file 3: Mandibular fractures.

References

1. Costello BJ, Papadopoulos H, Ruiz R. Pediatric craniomaxillofacial trauma. Clin Pediatr Emerg Med. 2005;6(1):32-40.

2. Boden BP, Tacchetti R, Mueller FO. Catastrophic injuries in high school and college baseball players. Am J Sports Med. Jul-Aug 2004;32(5):1189-96. [Medline].

3. Schulz RC. Facial Injuries. 2^nd ed. Chicago, Ill: Yearbook Medical Publishers, Inc; 1977.

4. Laskin DM. Protecting the faces of America. J Oral Maxillofac Surg. Apr 2000;58(4):363. [Medline].

5. Romeo SJ, Hawley CJ, Romeo MW, Romeo JP. Facial injuries in sports: a team physician's guide to diagnosis and treatment. Phys Sportsmed. Apr 2005;33(4):45-53. [Full Text].

6. Tanaka N, Hayashi S, Suzuki K, et al. [Clinical study of maxillofacial fractures sustained during sports and games] [Japanese]. Kokubyo Gakkai Zasshi. Sep 1992;59(3):571-7. [Medline].

7. Iida S, Kogo M, Sugiura T, Mima T, Matsuya T. Retrospective analysis of 1502 patients with facial fractures. Int J Oral Maxillofac Surg. Aug 2001;30(4):286-90. [Medline].

8. Bak MJ, Doerr TD. Craniomaxillofacial fractures during recreational baseball and softball. J Oral Maxillofac Surg. Oct 2004;62(10):1209-12. [Medline].

9. Reyes Mendez D, Lapointe A. Nasal trauma and fractures in children. UpToDate [serial online]. May 2007;Accessed September 14, 2007. Available at www.UpToDate.com.

10. Neuman MI, Bachur RG. Orbital fractures. UpToDate [serial online]. September 2006;Accessed September 14, 2007. Available at www.UpToDate.com.

11. Schwab RA, Genners K, Robinson WA. Clinical predictors of mandibular fractures. Am J Emerg Med. May 1998;16(3):304-5. [Medline].

12. Tesini DA, Soporowski NJ. Epidemiology of orofacial sports-related injuries. Dent Clin North Am. Jan 2000;44(1):1-18, v. [Medline].

13. Baker SM, Hurwitz JJ. Sports and industrial ophthalmology: management of orbital and ocular adnexal trauma. Ophthalmol Clin North Am. 1999;12:435-55.

14. Christensen GR. Eye injuries in sports: evaluation, management, and prevention. In: Mellion MB, Walsh WM, Shelton GL, eds. The Team Physician's Handbook. 2^nd ed. Philadelphia, Pa: Hanley & Belfus, Inc; 1997:407-25.

15. Dominguez S. Maxillofacial trauma. In: Markovchick VJ, Pons PT, eds. Emergency Medicine Secrets. 2^nd ed. Philadelphia, Pa: Hanley & Belfus, Inc; 1999:404-7.

16. Ellis E 3rd, Scott K. Assessment of patients with facial fractures. Emerg Med Clin North Am. Aug 2000;18(3):411-48, vi. [Medline].

17. Hendler BH. Maxillofacial Trauma. In: Rosen P, Barken R, eds. Emergency Medicine Concepts and Clinical Practice. 4^th ed. St. Louis, Mo: Mosby-Year Book; 1998:1098-103.

18. Kaufman BR, Heckler FR. Sports-related facial injuries. Clin Sports Med. Jul 1997;16(3):543-62. [Medline].

19. Thomas SH. Maxillofacial injuries. In: Harwood-Nuss AL, ed. The Clinical Practice of Emergency Medicine. Philadelphia, Pa: Lippincott Williams & Wilkins; 1996:408-18.

20. Tu HK, Davis LF, Nique TA. Maxillofacial injuries. In: The Team Physician's Handbook. 2^nd ed. Philadelphia, Pa: Hanley & Belfus, Inc; 1997:426-37.

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

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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