Face Fracture 

Updated: Oct 24, 2016
Author: Thomas Widell, MD; Chief Editor: Steven C Dronen, MD, FAAEM 

Overview

Background

Maxillofacial fractures result from blunt or penetrating trauma.[1, 2, 3, 4, 5, 6, 7] 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. Simple nasal fractures are the most common of all facial fractures.  Zygomatic arch fractures generally occur in 2 or 3 locations along the arch. Zygomaticomaxillary, ot tripod, fractures occur at articulations of the zygoma with the frontal bone maxillae and zygomatic arch. Alveolar fractures occur just above the level of the teeth through the alveolar portion of the maxilla. Le Fort or midface fractures are classified as types I, II, and III. Type I fracture extends through the lower third of the septum and involves the maxillary sinus. Type II (pyramidal) fracture extends from the nasal bone, through the lacrimal bone, and down through the zygomaticomaxillary suture.Type III fracture separates facial bones from the cranium, causing the face to appear long and flat.

See the image below.

Le Fort fractures. Le Fort fractures.

Endotracheal anesthesia and radiography developed during the First World War led to better understanding and treatment of facial fractures.[8] 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

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 facial fractures and 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.

Epidemiology

Approximately 3 million facial injuries occur annually, but most do not involve maxillofacial fractures.[8, 4, 5, 6, 7, 9, 1] 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.

In a 10-year retrospective study of the incidence and etiology of maxillofacial trauma associated with brain injury, frontal sinus fractures were the most common maxillofacial fractures (21.9%) associated with neurosurgical input, followed by mandibular fractures and zygomatic complex fractures. In the general maxillofacial trauma population, frontal sinus fractures were only found in 2.2% of the cases. The main cause of injury was automobile accidents, followed by falls.[10]

A study of complications in patients with maxillofacial trauma found that patients in car collisions were most likely to develop complications (92.3%), followed by falls (66.7%). Patients aged 60-69 years experienced the highest complication rate, followed by patients aged 20-29 years and then 30-39 years. The majority of complications were infection and inflammation (36.4%), followed by neurologic deficit (24.0%), physiologic dysregulation (11.6%), and facial bone deformity (8.3%). The most common treatment was pharmacologic, followed by antibiotic treatment, conservative treatment, and decompression therapy.[11]

Age and 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.

Male predominance is reduced to 3:2 in children. Child abuse should be suspected, particularly in nonmotor vehicular injuries. The incidence of maxillofacial fractures has increased in older patients.[12]

In a study of facial fractures in the elderly (>64 yr) compared with those in younger patients, elderly patients tended to experience less severe facial fractures and were more likely to have experienced injury from a fall. Compared to younger patients, the older patients sustained a higher incidence of maxillary, nasal, and orbital floor fractures and a lower incidence of mandible fractures.[13]

A study of 336,124 ED visits were for facial fractures in those no older than 21 years found that the most common facial fractures were those of the nasal bones and mandible. Younger children were more likely to have falls, pedal cycle accidents, pedestrian accidents, and transport accidents, whereas older groups were more likely to have firearm injuries, motor vehicle traffic accidents, and assaults.[3]

Patient Education

If band arch wires are placed, teach patients how to release the crossband in an emergency.

Give instructions for epistaxis if this has occurred.

Discuss the risk of posttraumatic stress disorder.[14]

For patient education resources, see the Back, Ribs, Neck, and Head Center and Breaks, Fractures, and Dislocations Center, as well as Black Eye.

 

Presentation

History

 

The First priority is to perform a primary survey and attend to ABCs, as maxillofacial fractures are caused by significant trauma.[4, 5, 6, 7] 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, such as the following:

  • Allergies

  • Medications

  • Past medical history

  • Last meal

  • Events leading to injury

Ask specific questions regarding injury, such as the following:

  • What was the mechanism of injury?

  • Did the patient lose consciousness?

  • Has the patient had any visual problems such as double or blurred vision?[15]

  • 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. Below, portions of the examination specific for facial bones are marked with an asterisk (*)[16] :

  • 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.*[15, 17]

  • 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*,[18] 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.[19]

  • 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.[15]

  • 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.

 

DDx

 

Workup

Laboratory Studies

Base the need for laboratory studies upon extent of concomitant nonfacial trauma.

If injuries are isolated to face and surgery is planned, order preoperative laboratory tests.

Imaging Studies

Nasal bone fractures

Nasal bone fractures can be diagnosed clinically by history and physical examination. Plain nasal films consisting of a lateral view coning down on the nose and a Waters view can confirm the diagnosis but are of little practical use. If edema has resolved and no deformity is noted, x-rays are unnecessary.[20, 21]

If deformity persists after resolution of edema, films may be obtained at follow-up to help plan the repair. Omission of ED films is cost-effective, since most nasal fractures do not need to be reduced.

A study comparing ultrasonography with computed tomography in the diagnosis of nasal bone fractures concluded there was no significant difference in findings.[22]

Nasoethmoidal fracture

If nasal fracture is suspected and evidence suggests ethmoidal bone involvement, such as CSF rhinorrhea or widening of the nasal bridge with telecanthus, plain films are of little use.

Coronal CT scan of the facial bones is the best test to determine the extent of fracture.[21, 23, 24] A 3-D reconstruction may help the consultant should surgery be required.

Zygoma fracture

The best film for evaluating zygomatic arch is an underexposed submental view, also known as bucket handle view, because arches appear as bucket handles.

Fracture also can be seen on a Waters view, and in some cases on a Towne view, of a facial series.

Tripod fracture

If tripod fracture is suspected, plain films should include Waters, Caldwell, and underexposed submental views.

Waters view is best to evaluate the inferior orbital rim, maxillary extension of the zygoma, and the maxillary sinus.

Caldwell view evaluates the frontal process of the zygoma and the zygomaticofrontal suture.

Underexposed submental view evaluates the zygomatic arch.

Coronal CT scan of facial bones often is used to better evaluate these fractures, especially with use of 3-D reconstruction to improve visualization of the fracture for reduction. If tripod fracture is suspected strongly, obtaining CT scan directly without plain films is probably most cost-effective.[23, 24]

Le Fort fractures

Coronal CT scan of facial bones has replaced plain films in evaluation of Le Fort fractures, especially with use of 3-D reconstruction. Since Le Fort fractures often are mixed from one side to the other, CT scan is superior to plain films and makes visualization of the fracture for repair much easier. If CT is not available, a facial series with lateral, Waters, and Caldwell views can be used to evaluate the fracture. Almost all Le Fort fractures cause blood to collect in the maxillary sinus.[20, 23, 24]

Imaging of Le Fort I fractures demonstrates a fracture extending horizontally across the inferior maxilla, sometimes including a fracture of the lateral sinus wall, extending into the palatine bones and pterygoid plates.

Imaging of Le Fort II fractures demonstrates disruption of the inferior orbital rim lateral to the infraorbital canal and a fracture of the medial orbital wall and nasal bone. The fracture extends posteriorly into the pterygoid plates.

Imaging of Le Fort III fractures demonstrates fractures at the zygomaticofrontal suture, zygoma, medial orbital wall, and nasal bone extending posteriorly through the orbit at the pterygomaxillary suture into the sphenopalatine fossa.

Other Tests

Perform chest films if teeth are missing to rule out tooth aspiration.

Test clear rhinorrhea for glucose. Nasal secretions, unlike CSF, are normally low in glucose. If blood is present, this test is unreliable. Blood-tinged fluid can be placed on filter paper to look for a double ring sign of CSF around blood, but this is not a reliable test.

Procedures

When CSF rhinorrhea is suspected, fluorescein may be injected into the lumbar subarachnoid space. Observe with a Wood lamp 30 minutes later for fluorescence of nasal discharge; if present, this confirms CSF rhinorrhea. This procedure is not usually performed by emergency physicians.

 

Treatment

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.

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.[1]

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.

Facial fractures tend to be very painful. Provide adequate analgesia, including oral opioids and NSAIDs. If nasal packing is used, antibiotics are generally used to prevent toxic shock.[25]

Patients with simple nasal fractures can be discharged home with follow-up in 5-7 days when edema has decreased. Avoid delaying follow-up care, because fracture healing may begin prior to a necessary reduction. Give patients epistaxis instructions and instruct to return if clear fluid from nose is noted.

Patients with simple zygomatic arch fractures, without trismus or mouth opening problems, can be discharged home with proper follow-up care.

Patients with tripod fractures without eye involvement can be discharged home with appropriate follow-up care.

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]

Medical Care

Patients with NOE fractures generally require admission to monitor for a CSF leak and observe for signs of meningitis or brain abscess, which are known complications.

Patients with zygomatic arch fractures who have significant trismus or inability to open the mouth may require admission for observation because of potential problems with aspiration or airway obstruction from vomiting.

Patients with tripod fractures with eye involvement generally require admission to ophthalmology.

Patients with Le Fort fractures may require admission for further workup prior to open reduction and internal fixation. Patients also may need a short admission if arch wires are used, because of the risk of obstruction or aspiration should they vomit. During the hospital stay, teach patients how to remove the crossband so the mouth can be opened if they need to vomit.

Patients with multiple traumas should be admitted to a surgeon with trauma experience to coordinate care of all injuries.

The incidence of posttraumatic stress disorder is high in patients with facial injuries, and consultation with a psychiatrist should be considered.[14]

Complications

Continued CSF leaks can occur, although most stop by 2-3 weeks after the injury.

Meningitis and abscesses are serious infections that can occur when a CSF leak is present. Observe patients closely for signs and symptoms.

Other complications include the following:

  • Sepsis
  • Scars and facial deformity
  • Injury to infraorbital nerve in tripod and Le Fort II fractures that extends through the infraorbital foramen where the nerve exits
  • Posttraumatic stress disorder [14]

Prevention

Use of seatbelts and airbags can reduce incidence of facial injuries in motor vehicle accidents. Use of helmets with facial guards can reduce injury in motorcycle accidents and in accidents in such sports as skiing, snowboarding, hockey, and football.

 

Medication

Medication Summary

When airway control is needed, rapid sequence induction often is the preferred method. Perform rapid sequence induction, using medications to induce unconsciousness and muscle paralysis to facilitate intubation. A cricothyroidotomy kit should be at bedside if oral intubation cannot be accomplished.

Provide adequate analgesia, including opioids, NSAIDs, or local anesthetics. Prophylactic antibiotics are controversial when a CSF leak is identified or when the fracture involves the sinuses. It is usually left to the discretion of the specialist assuming care of the patient. If the nares has been packed for epistaxis, prophylactic antibiotics should be used to prevent infection, including toxic shook syndrome. If the patient has an open wound, update tetanus immunization.

Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

These drugs are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis.

Naproxen (Anaprox, Naprelan, Naprosyn)

For relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis.

Flurbiprofen (Ansaid)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patients for response.

Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen (Tylenol, Panadol, aspirin-free Anacin)

DOC for treatment of pain in patients with documented hypersensitivity to aspirin and NSAIDs, those with upper GI disease, or those taking oral anticoagulants.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Oxycodone and aspirin (Percodan)

Drug combination indicated for relief of moderately severe to severe pain.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

DOC for narcotic analgesia due to its reliable and predictable effects, safety, and ease of reversibility with naloxone. Morphine sulfate administered IV may be dosed in a number of ways and commonly is titrated until desired effect obtained.

Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Cephalexin (Biocef, Keflex, Keftab)

First-generation cephalosporin that inhibits bacterial replication by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls.

Resistance occurs by alteration of penicillin-binding proteins. Effective for treatment of infections caused by streptococcal or staphylococci, including penicillinase-producing staphylococci. May use to initiate therapy when streptococcal or staphylococcal infection is suspected.

Used orally when outpatient management is indicated.

Sulfamethoxazole and trimethoprim (Bactrim, Bactrim DS, Septra, Septra DS)

Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.

Amoxicillin and clavulanate (Augmentin, Augmentin XR)

Amoxicillin inhibits bacterial cell wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits beta-lactamase producing bacteria.

Good alternative antibiotic for patients allergic or intolerant to the macrolide class. Usually is well tolerated and provides good coverage to most infectious agents. Not effective against Mycoplasma and Legionella species. The half-life of oral dosage form is 1-1.3 h. Has good tissue penetration but does not enter cerebrospinal fluid.

For children > 3 months, base dosing protocol on amoxicillin content. Because of different amoxicillin/clavulanic acid ratios in 250-mg tab (250/125) vs 250-mg chewable tab (250/62.5), do not use 250-mg tab until child weighs >40 kg.

Anxiolytics

Class Summary

Patients with painful injuries usually experience significant anxiety. Anxiolytics allow a smaller analgesic dose to achieve the same effect.

Lorazepam (Ativan)

Sedative hypnotic in benzodiazepine class that has short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation. Excellent for sedating patients for longer than 24-h period. Monitor patient's BP after administering dose. Adjust as necessary.