Approach Considerations
Facial fractures that necessitate urgent evaluation and management include the following [2] :
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Nasoethmoid fractures to monitor for cerebrospinal fluid (CSF) leak and possible complications including meningitis
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Zygomatic arch fractures associated with trismus to observe for potential airway complications
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LeFort-type fractures of the midface requiring surgical repair
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Facial fractures in patients with multiple other significant injuries
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Tripod fractures associated with ocular findings require emergent ophthalmologic evaluation and management
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 utilizing fine cuts and both coronal and sagittal reconstructions is the study of choice when evaluating facial fractures because visualization of fractures among the complex curves of facial bones is best achieved using this modality. (Ref 29) Radiographic evaluation, however, should not be substituted for a complete external and internal examination. [18] See the following:
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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.
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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.
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Nasal fractures: Radiographs are not usually necessary to diagnose this injury. Plain radiographs, moreover, are often not helpful in diagnosing nasal fractures in children since the nasal bones of children are poorly visualized on plain radiograph because they are not fused and are composed primarily of cartilage. [18] 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.
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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.
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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. Radiographically, Le Fort I fracture is the only one of the 3 Le Fort fractures to involve the nasal fossa; Le Fort II fracture is the only one of the 3 Le Fort fractures to involve the inferior orbital rim; and Le Fort III fracture is the only one of the 3 Le Fort fractures to involve the zygomatic arch. [6]
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Mandibular fractures: The study of choice is panoramic radiography. Simple radiographs of the mandible are less sensitive for detecting fractures when compared to panoramic radiographs and can miss condylar fractures. (Ref 29) 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. A case series of 102 mandible fractures assessed by CT scanning demonstrated 42 percent involved only a single fracture rather than a pair of fractures as traditional teaching usually states. (Ref 29)
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.
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The bony walls of the orbit.
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Le Fort fractures.
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Mandibular fractures.
