Facial Fractures Clinical Presentation

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. In addition to obtaining a basic history of the injury and past medical problems, the clinician should seek to answer the following questions ^[15] :

• Can you breathe out of both sides of your nose?

• Are you having any trouble speaking?

• Do you have double vision or any other trouble with your vision?

• Is your hearing normal?

• Are you experiencing any numbness of your face?

• Have you had any previous facial injuries or surgeries, including procedures to correct vision (eg, LASIK [laser-assisted in situ keratomileusis])?

• Do your teeth come together the way they normally would?

• Are any of your teeth painful or loose?

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.

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

See the image below.

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

See the image below. The patient may report malocclusion and jaw pain or numbness.

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. ^[14]

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. ^[16]

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%. ^[16]

A study implemented a structured record keeping tool to improve clinical documentation since the authors found that basic ophthalmic examination and assessment of important clinical signs are often missing from the records of patients with facial injuries presenting to the emergency department. ^[17]