Typically blunt trauma from motor vehicle accidents, direct blows including assaults, or falls.
Consider physical assault and domestic violence, especially in women and children.
Open fractures common.
Many facial fractures are complex and are not easily classified.
Etiology
Le Fort fractures involve the maxilla and are classified as:
Le Fort I: Transverse fracture of maxilla below nose but above teeth through lateral wall of maxillary sinus to lateral pterygoid plate.
Le Fort II: Pyramidal fracture from nasal and ethmoid bones through zygomaticomaxillary suture and maxilla, often involving maxillary sinuses and infraorbital rims.
Le Fort III: Craniofacial disjunction with elongated, flattened face owing to fractures through frontozygomatic suture, orbit, base of nose, and ethmoid bone.
Le Fort IV: Includes frontal bone in addition to Le Fort III.
A patient may have different level Le Fort fractures on each side of the face.
Zygomatic arch fractures often occur in 2 or 3 places and can involve the orbit and maxilla (tripod fracture).
Inner plate frontal sinus fractures are associated with CSF leaks and ocular injuries.
Orbital fractures most commonly involve the orbital floor (blow-out fracture), and are commonly associated with ocular injuries but can involve the medial and lateral orbital walls.
Falls most common cause.
Zygoma most common bone fractured.
Beware of associated cervical and intracranial injuries.
Maxillofacial fractures rarely seen in children younger than 6 yr; suspect nonaccidental trauma.
Falls and motor vehicle accidents account for most cases.
Over 50% have severe associated injuries, high incidence of associated head injury.
Fractures of the orbit are the most common facial fracture in children (excluding nose)
Diagnosis
Signs and Symptoms
Most post-traumatic deformities of the face represent underlying fractures.
Facial anesthesia with nerve entrapment or injury.
Associated injuries; tooth, mandible, eye, tear duct, skull, and neck.
Bluish fluid-filled sac overlying nasal septum is a septal hematoma and is critical to detect.
History
Mechanism of injury.
Associated injuries.
Physical Exam
Immediately assess airway.
Most important:
Palpate entire face for tenderness, step-offs, depressions, and crepitus.
Check for mandibular injuries or malocclusion.
Nasal speculum exam for septal hematoma or CSF leak.
Assess for areas of facial anesthesia.
Careful eye exam including funduscopic exam; obtain a visual acuity; assess for telecanthus (intercanthal width >30-35 mm), upward dysconjugate gaze (indicative of ocular muscle entrapment in an orbital floor blow-out fracture).
Le Fort fractures are assessed by placing thumb and index finger of 1 hand on the bridge of the nose and pulling upper teeth with other hand:
Le Fort I: Movement of hard palate and maxillary dentition only (your hand on the nose will not feel movement).
Le Fort II: Movement of hard palate, maxillary dentition, and nose (your hand on the nose will feel movement).
Le Fort III: Movement of entire midface.
Sedation may be needed to perform an adequate exam.
Essential Workup
After airway is secured, other injuries take precedence.
Radiologic studies in all cases of suspected facial fractures.
Diagnosis Tests & Interpretation
Lab
Indicated for evaluation of associated injuries or if needed for preoperative reasons.
Imaging
Facial bone CT scanning with reconstructions is the imaging modality of choice for suspected facial injuries.
Plain films such as a Waters view are less helpful.
May show fractures, asymmetry, or blood in the sinuses, or the classic teardrop opacity in the maxillary sinus representing an orbital floor blow-out fracture.
Jug-handle views (submental vertex) may visualize zygomatic arch fractures.
Differential Diagnosis
Nasal fracture.
Zygoma fractures (arch or tripod fracture).
Le Fort fracture.
Skull fractures including frontal sinus fractures and cribriform plate fractures.
Nasofrontoethmoid complex fractures.
Mandibular fractures.
Orbital fracture including blow-out fracture
Associated injuries to teeth, neck, and brain.
Contusions or lacerations without underlying fractures.
Treatment
Pre-Hospital
Airway control takes precedence:
Attempt chin lift, jaw thrust, and suctioning first.
Underlying injuries may make these attempts as well as use of bag/valve/mask (BVM) device unsuccessful.
Severe facial fractures may preclude oral intubation.
Nasotracheal intubation contraindicated in massive facial or nasal trauma.
Cricothyroidotomy performed if intubation using rapid-sequence induction (RSI) cannot be performed.
If associated injuries are present, protect cervical spine.
Initial Stabilization/Therapy
Aggressively manage airway if not patent, patient requires airway protection, or ongoing swelling or bleeding threatens airway. RSI is initial airway management of choice in facial injuries; use etomidate or midazolam and vecuronium, rocuronium, or succinylcholine for RSI.
Surgical airway (cricothyroidotomy or needle cricothyroidotomy) may be required if RSI is unsuccessful.
Nasotracheal intubation is contraindicated in most facial fractures.
Protect cervical spine until clinically or radiographically cleared.
Once airway is secure, other major injuries take precedence over facial injuries.
Bleeding may be difficult to control and may require posterior packing if direct pressure does not work.
Ed Treatment/Procedures
Consult ear, nose, throat specialist; plastic surgery; or oral surgery for complex fractures, including all Le Fort fractures, and neurosurgery for frontal sinus fractures involving the posterior table.
Antibiotics (cefazolin or clindamycin in penicillin-allergic patients) for open fractures and CSF leak.
Tetanus prophylaxis.
Parenteral pain medication (morphine or fentanyl).
A septal hematoma must be drained in the ED:
Anesthetize, aspirate with an 18G-20G needle, and pack both nares with Vaseline gauze.
Discharge on amoxicillin or erythromycin with recheck in 24 hr by ear, nose, and throat specialist.
Nondisplaced zygomatic fractures can be discharged with analgesics (acetaminophen or ibuprofen); refer displaced zygoma and tripod fractures that are otherwise stable for outpatient reduction in 2-3 days after swelling is reduced.
Overlying lacerations with simple fractures can be sutured in the emergency department; if patient is discharged, treat with amoxicillin or azithromycin.
Patients discharged with facial fractures with blood in the sinus should be treated with amoxicillin or azithromycin.
Surgical cricothyroidotomy should not be performed in children younger than 8 yr:
Needle cricothyroidotomy with jet ventilation may be performed.
Children are at high risk of associated injuries.
Repair of facial fractures should not be delayed more than 3-4 days (rapid healing of facial fractures and the risk of malunion and cosmetic deformity).
Medication
Acetaminophen: 500 mg (peds: 10-15 mg/kg, do not exceed 5 doses/24 h) PO q4-6h, do not exceed 4 g/24 h
Amoxicillin: 250 mg (peds: 40-80 mg/kg/24 h) PO q8h
Azithromycin: 500 mg PO day 1 followed by 250 mg PO days 2-4 (peds: 10 mg/kg PO day 1 followed by 5 mg/kg days 2-4)
Cefazolin: 1 g (peds: 50-100 mg/kg/24 h) IV or IM
Clindamycin: 600-900 mg (peds: 25-40 mg/kg/24 h) PO q8h
Diazepam: 5-10 mg (peds: 0.1-0.2 mg/kg) IV
Etomidate: 0.2-0.3 mg/kg (peds: 0.2-0.3 mg/kg) IV (not recommended in children <10 yr)
Fentanyl: 2-10 μg/kg (peds: 2-3 μg/kg) IV
Ibuprofen: 600-800 mg (peds: 20-40 mg/kg/24 h) PO TID-QID
Ketamine: 1-2 mg/kg (peds: 1-2 mg/kg) IV
Midazolam: 2-5 mg (peds: 0.02-0.05 mg/kg per dose, max. dose 0.4 mg/kg total and not >10 mg) IV over 2-3 min
Morphine sulfate: 0.1-0.2 mg/kg (peds: 0.1-0.2 mg/kg) IV q1-4h titrated
Rocuronium: 0.6-1.2 mg/kg (peds: 0.6 mg/kg) IV
Succinylcholine: 1-1.5 mg/kg (peds: 1-2 mg/kg) IV
Vecuronium: 0.1-0.3 mg/kg (peds: 0.1-0.3 mg/kg) IV
Follow-Up
Disposition
Admission Criteria
Significant associated trauma.
Airway compromise.
Le Fort II and III fractures.
CSF leak.
Posterior table frontal sinus fractures.
Most open fractures, excluding simple nasal fractures with lacerations.
Discharge Criteria
No evidence of significant head, neck, or other injuries.
Closed fractures of the zygoma, orbit, sinus, or anterior table of the frontal sinus with appropriate follow-up in 24-36 hr.
Septal hematomas that have been drained in the emergency department require follow-up in 24 hr.
Refer displaced zygoma and tripod fractures that are otherwise stable for outpatient reduction in 2-3 days after swelling is reduced.
Issues for Referral
ENT, plastic surgery, or neurosurgery may all handle facial fractures, actual referral depends on practice patterns at your institution. If there is no CSF leak or involvement of the posterior table of the frontal sinus, it is reasonable to initially consult ENT.
Pearls and Pitfalls
Facial fractures and injuries can be very dramatic in appearance.