Facial Fractures

[Section Outline]

Description
Etiology

Author:

David W.Munter

Description

Typically blunt trauma from motor vehicle accidents, sports, direct blows including assaults, or falls
Gunshot wounds are another common cause
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

Most common are nasal bone, orbital floor, zygomatic bone, maxillary sinus
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

Geriatric Considerations
Falls most common cause Zygoma most common bone fractured (after nasal fractures) Beware of associated cervical and intracranial injuries

Pediatric Considerations
Maxillofacial fractures rarely seen in children <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 ⬆ ⬇

[Section Outline]

Signs and Symptoms
Essential Workup
Diagnostic Tests & Interpretation
Differential Diagnosis

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, mand ible, 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
- Raccoon eyes - periorbital ecchymosis, sometimes takes hours to develop, concerning for basilar skull fracture or orbital fracture
- Battle sign - ecchymosis behind the ear, concerning for mastoid or basilar fracture
- Check for mand ibular 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; loss of vision indicates an injury to the optic nerve or the globe; assess for telecanthus (intercanthal width >30-35 mm), upward disconjugate 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 one hand on the bridge of the nose and pulling upper teeth with the 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 bodily injuries take precedence after facial fractures
Radiologic studies in all cases of suspected facial fractures

Diagnostic 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-hand le views (submental vertex) may visualize zygomatic arch fractures
Panorex in cases of suspected mand ibular 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
Mand ibular fractures
Orbital fracture including blow-out fracture
Associated injuries to teeth, neck, and brain
Contusions or lacerations without underlying fractures

Treatment ⬆ ⬇

[Section Outline]

Prehospital
Initial Stabilization/Therapy
ED Treatment/Procedures
Medication

Prehospital

ALERT

Airway control takes precedence while protecting the c-spine:
- Attempt chin lift, jaw thrust, and suctioning first
- Underlying injuries may make these attempts and the 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, as 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
The use of antibiotics (cefazolin or clindamycin in penicillin-allergic patients) for open fractures and CSF leak is controversial, the evidence is strongest for penetrating trauma or bites and weakest for blunt trauma Should be administered, especially in the case of CSF leak, in conjunction with consultant
Tetanus prophylaxis
Parenteral pain medication (morphine or fentanyl)
A septal hematoma must be drained in the ED:
- Anesthetize, aspirate with an 18-20G needle, and pack both nares with Vaseline gauze
- Discharge on amoxicillin or erythromycin (evidence for the use of antibiotics is weak but still often recommended) 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 d after swelling is reduced
Overlying lacerations with simple fractures can be sutured in the ED; if patient is discharged, treat with amoxicillin or azithromycin, evidence for the use of antibiotics in open fractures is controversial, weak for blunt trauma, stronger in penetrating trauma
Patients discharged with facial fractures with blood in the sinus may be treated with amoxicillin or azithromycin, many consultants no longer recommend this

Pediatric Considerations

Most commonly due to falls, sports, and MVAs
Nasal bone and mand ible most commonly fractured
Surgical cricothyroidotomy should not be performed in children <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 d (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 hr) PO q4-6h, do not exceed 4 g/24 hr
Amoxicillin: 250 mg (peds: 40-80 mg/kg/24 hr) 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 q8h (peds: 50-100 mg/kg/24 hr divided q8h) IV/IM
Clindamycin: 600-900 mg (peds: 25-40 mg/kg/24 hr) 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 mcg/kg (peds: 2-3 mcg/kg) IV
Ibuprofen: 600-800 mg (peds: 20-40 mg/kg/24 hr) PO t.i.d-q.i.d
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 ED require follow-up in 24 hr
Refer displaced zygoma and tripod fractures that are otherwise stable for outpatient reduction in 2-3 d after swelling is reduced

Issues for Referral

ENT, plastic surgery, or neurosurgery may all hand le 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
- Airway management always takes precedence. Avoid nasotracheal intubation
- After the airway is secured as necessary, evaluation of other injuries takes precedence - do not miss life-threatening injuries
  - Cervical spine
  - Pulmonary or thoracic
  - Intra-abdominal injuries
Have a low threshold for obtaining facial bone CT for evaluation of facial injuries
Facial fractures are frequently associated with ocular injuries. Perform a thorough eye exam
Loss of vision is a significant finding and implies an injury to the globe or the optic nerve
Always assess for a nasal septal hematoma
Missing teeth must be accounted for, obtain a CXR to rule out aspiration

Additional Reading ⬆ ⬇

BoswellKA. Management of facial fractures . Emerg Med Clin North Am. 2013;31(2):539-551.
DoerrTD. Evidence-based facial fracture management . Facial Plast Surg Clin North Am. 2015;23(3):335-345.
DoughertyWM, ChristophelJJ, ParkSS. Evidence-based medicine in facial trauma . Facial Plast Surg Clinic North Am. 2017;25(4):629-643.
Radiology of Facial Fractures from Department of Radiology at the University of Washington: http://rad.washington.edu/about-us/academic-sections/musculoskeletal-radiology/teaching-materials/online-musculoskeletal-radiology-book/facial-and -mand ibular-fractures/

See Also (Topic, Algorithm, Electronic Media Element)

Codes ⬆

ICD9

802.4 Closed fracture of malar and maxillary bones
802.6 Closed fracture of orbital floor (blow-out)
802.8 Closed fracture of other facial bones
802.9 Open fracture of other facial bones
802.5 Open fracture of malar and maxillary bones
802.7 Open fracture of orbital floor (blow-out)

ICD10

S02.3XXA Fracture of orbital floor, init encntr for closed fracture
S02.92XA Unsp fracture of facial bones, init for clos fx
S02.401A Maxillary fracture, unsp, init encntr for closed fracture
S02.402A Zygomatic fracture, unsp, init encntr for closed fracture
S02.402B Zygomatic fracture, unsp, init encntr for open fracture
S02.411A LeFort I fracture, initial encounter for closed fracture
S02.411B LeFort I fracture, initial encounter for open fracture
S02.412A LeFort II fracture, initial encounter for closed fracture
S02.412B LeFort II fracture, initial encounter for open fracture
S02.413A LeFort III fracture, initial encounter for closed fracture
S02.413B LeFort III fracture, initial encounter for open fracture
S02.8XXA Fractures of oth skull and facial bones, init for clos fx
S02.92XB Unsp fracture of facial bones, init encntr for open fracture

SNOMED

430984009 Closed fracture of facial bone (disorder)
263156006 Fracture of maxilla
263167007Blow out fracture of orbit (disorder)
263165004 Fracture of zygomatic process (disorder)
111609001 Open fracture of facial bones (disorder)
27477003 fracture of face bones (disorder)
37027003 Le Fort's fracture, type III (disorder)
44916009 Le Fort's fracture, type II (disorder)
48407005 Le Fort's fracture (disorder)
63669006 Le Fort's fracture, type I (disorder)
95851007 Fracture of orbit (disorder)

section name header

Basics ⬇

Geriatric Considerations

Pediatric Considerations

Diagnosis ⬆ ⬇

History

Physical Exam

Pediatric Considerations

Lab

Imaging

Treatment ⬆ ⬇

ALERT

Pediatric Considerations

Follow-Up ⬆ ⬇

Admission Criteria

Discharge Criteria

Issues for Referral

Pearls and Pitfalls ⬆ ⬇

Additional Reading ⬆ ⬇

Codes ⬆