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Facial Fractures: Treatment & Medication
Updated: Mar 14, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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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.
Related Medscape topics:
Resource Center Sepsis
Resource Center Wound Management
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:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
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.
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
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
Documented hypersensitivity; aspirin/NSAID-induced asthma; third trimester of pregnancy
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.
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
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
Documented hypersensitivity; known G6PD
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.
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
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
Documented hypersensitivity; depressed respiratory function; increased ICP; acute abdominal pain; pseudomembranous colitis; toxin-related diarrhea; impaired liver function
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.
Adult
1 tab or cap PO q6h
Pediatric
Not established
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
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)
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.
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
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
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding; administration into CNS
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.
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
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
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
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.
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
May have additive effects when used concurrently with other CNS depressants or anticonvulsants; coadministration with epinephrine may cause hypotension
Documented hypersensitivity; glaucoma, narrow-angle; lactation; children younger than 2 y (incidences of death due to respiratory depression)
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.
Adult
4 mg/dose IV
Alternatively, 0.15 mg/kg/dose PO
Pediatric
Not established
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
Documented hypersensitivity
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
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
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
