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, enophthalmos, 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. [14] Orbital fractures that involve a sinus should receive antibiotic prophylaxis. [19]
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. [7] 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.
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. Special consideration should be given to the athlete who suffers a traumatic injury that involves the globe—emergent evaluation by an ophthalmologist is recommended. [19]
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The bony walls of the orbit.
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Le Fort fractures.
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Mandibular fractures.
