SIGNS AND SYMPTOMS 
- Most post-traumatic deformities of the face represent underlying fractures.
- Pain, swelling, ecchymosis, and deformity.
- CSF rhinorrhea, facial hemorrhage, epistaxis, raccoon eyes.
- 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.
Pediatric Considerations
- 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.
[Outline]
PRE-HOSPITAL
ALERT
- 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.
Pediatric Considerations
- 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
[Outline]
- Chapman VM, Fenton LZ, Gao D, et al. Facial fractures in children: Unique patterns of injury observed by computed tomography. J Comput Assist Tomogr. 2009;33(1):70–72.
- Cole P, Kaufman Y, Hollier L. Principles of facial trauma: Orbital fracture management. J Craniofac Surg. 2009;20(1):101–104.
- Grunwaldt L, Smith DM, Zuckerbraun NS, et al. Pediatric facial fractures: Demographics, injury patterns, and associated injuries in 772 consecutive patients. Plast Reconstr Surg. 2011;128(6):1263–1271.
- Kontio R, Lindqvist C. Management of orbital fractures. Oral Maxillofac Surg Clin North Am. 2009;21(2):209–220.
- Sharabi SE, Koshy JC, Thornton JF, et al. Facial fractures. Plast Reconstr Surg. 2011;127(2):25e–34e.
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