M a n a g e m e n t o f F a c i a l F r a c t u res

Kim A. Boswell, MD

KEYWORDS
 Frontal sinus fractures  Zygomaticomaxillary complex fractures  LeFort fractures
 Orbital fractures  Naso-orbital ethmoid fractures  Nasal fractures

KEY POINTS
 Facial trauma is commonly seen in the emergency department and presents the emer-
gency physician with potentially life-threatening conditions and associated injuries,
including brain and cervical spine injuries.
 Facial fractures are often a part of a constellation of injuries, and the emergency physician
should be comfortable recognizing these patterns.
 Frontal fractures require significant force and are often associated with neurologic injury.
 LeFort fractures can be unilateral or bilateral, but all types require involvement of the pterygoid
plates.
 Orbital fractures can be subtle and in their presence a full neurologic examination, including
evaluation of the cranial nerves, should be performed. Extraocular muscle entrapment is an
indication for emergent surgery.
 Surgical intervention of facial fractures is usually not emergent. In those patients who can
be safely discharged, good discharge instructions and close follow-up with a facial
surgeon are imperative.

The emergency physician must often evaluate patients with facial injuries, including
several types of facial fractures. As is typical in our work, we must rapidly determine
a patient’s stability, placing emergent emphasis on airway, breathing, and circulation.
Identifying life-threatening injuries is what we are trained to do; in the setting of facial
trauma, these can include bleeding, airway compromise, and associated head or spinal
injuries. Most facial fractures are stable injuries that can be addressed with local wound
care and appropriate and prompt referral for definitive treatment within the following few
days. However, some facial fractures are considered unstable and require more urgent
evaluation and treatment. Some fractures are associated with injuries to the cervical
spine, globes, dental structures, or lacrimal system. A widely appreciated association
is cervical spine injury in conjunction with facial fractures. The incidence of cervical spine
fracture has been cited as between 0.3% and 24.0%,1 but the risk increases with more
severe and more numerous facial fractures. It is the emergency physician’s responsibility
to identify each fracture, understand specific injury patterns, and diagnose commonly
associated injuries to the surrounding soft tissue, neurologic structures, or vasculature.

Disclosure: Nothing to disclose.

Surgical Critical Care, Shock Trauma Center, 22 South Greene Street, Baltimore, MD 21201, USA
E-mail address: [email protected]

Emerg Med Clin N Am 31 (2013) 539–551

http://dx.doi.org/10.1016/j.emc.2013.01.001 emed.theclinics.com
0733-8627/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.
540 Boswell

GENERAL ASSESSMENT

Individuals who present with facial fractures usually have been involved in assaults,
motor vehicle crashes, sporting or occupational injuries, or falls. As mentioned previ-
ously, initial stabilization of life-threatening injuries is the first priority. Then a general
evaluation focusing on the region of the trauma should be performed on every patient
with facial injury. Starting with palpation of the facial structure can provide an indica-
tion of underlying injury that may not be readily apparent and can elicit instability, as is
characteristic of LeFort fractures. Palpation of the cervical spine should be routine
practice in the evaluation of patients with facial trauma.
A preliminary visual assessment should be performed in every patient, as well as
a full visual acuity, fluorescein/slit-lamp examination in those with injuries to the
surrounding structures. If the physician is concerned about globe rupture or lacera-
tion, the patient’s eye should be covered with a metal shield to prevent any pressure
from being placed on it until an ophthalmologist can evaluate the patient. Pressure can
result in worsening of the injury and permanent vision loss.
Jaw or dental injuries should be evaluated by having patients occlude their teeth.
Any malocclusion, difficulty in maintaining a firm bite, or significant pain with jaw
opening should raise concern about a mandibular fracture. Intraoral evaluation is
essential so that an alveolar ridge or open mandibular fracture is not missed.
A cranial nerve examination should be performed to rule out extraocular muscle
entrapment, paresthesias resulting from nerve damage, and impingement.

FRONTAL SINUS FRACTURES

The frontal bone creates the outward appearance of the forehead and is considered
part of the skull. For this reason, fractures of the frontal sinus are actually defined
as skull fractures.
Anatomy
We are born with a frontal bone but without frontal sinuses. The frontal sinuses begin
to develop at the age of 1 or 2 years and are not fully developed to adult size until
approximately 12 years of age. In teenagers and adults, the frontal bone is a divided,
air-filled structure, pyramidal in shape. It contains the sinus between an anterior and
a posterior wall, which are more commonly referred to as “tables.” The anterior table
is considered the structurally stronger of the two. Inferiorly, the superior orbital rim
defines the floor of the sinus. The floor of the frontal sinus composes a large portion
of the medial orbital roof. Immediately adjacent and adherent to the posterior table
is the dura. A posterior table fracture can be considered an open skull fracture that
could allow a cerebrospinal fluid (CSF) leak.
The nasofrontal duct (NFD) is the sole source of drainage for the frontal sinuses and
is intimately associated with the frontal bone. It lies against the posteromedial aspect
of the frontal sinus floor and is angled in an anterior and inferior direction. It drains into
the nasal cavity by way of the uncinate process. Only approximately 15% of the pop-
ulation has a true NFD, and the specific location and course of the NFD are subject to
significant individual variability.2
Epidemiology
The frontal bone is involved in 5% to 15% of facial fractures and includes fractures that
are isolated to either the anterior or posterior table or that involve both of them.3 The
frontal sinus is the strongest bone of the face. Significant force is needed to fracture it,
so patients with this injury should be considered at risk for other potentially significant
 Management of Facial Fractures 541

injuries. In fact, concomitant craniofacial injuries are present in approximately 56% to

87% of patients with frontal sinus fracture.4

Diagnosis and Management

Frontal bone fractures are most commonly diagnosed with computed tomography
(CT). Once diagnosed, several factors determine the need for consultation and
surgical intervention. The degree of displacement of the anterior table will affect the
cosmetic result once swelling has resolved; therefore, the greater the displacement,
the more likely surgical fixation will be necessary. Although the anterior table is the
structurally stronger component, the posterior table serves a more protective and
functionally important role than its counterpart. Given the proximity of the posterior
table to the dura mater and brain tissue, displaced fractures should heighten the
physician’s concern about possible damage to them. As for the anterior table, the
greater the displacement of the posterior table, the more likely is associated injury
to underlying structures. Comminution of the posterior table or obvious interruptions
in the dura increases the risk for CSF leak. Rhinorrhea from any patient with frontal
bone fractures should be considered a CSF leak until proven otherwise. Assessment
for the presence of b-2 transferrin is the current “gold standard” to diagnose a CSF
leak. Several other bedside tests have been proposed as ways of detecting CSF in
body fluids, including glucose testing and the halo test, but none is sensitive or
specific.
Frontal bone fractures are rarely an isolated injury, given the force required to induce
them. In the rare instance an isolated fracture is present, the patient’s disposition
depends on the severity of the injury and the presence or absence of associated
complications. Patients with an isolated, nondisplaced anterior table fracture with
no associated complications can be safely discharged home with close plastic surgery
(or facial surgery) follow-up. They should be discharged with nasal and oral deconges-
tants. It is recommended that they undergo repeat imaging to ensure proper healing
and prevention of complications at approximately 6 weeks.5 Patients who have frac-
tures that involve both tables, significant displacement, or comminution or who have
associated injuries should be admitted for close evaluation for CSF leak, ophthalmo-
logic evaluation, and potential surgical intervention.6

Complications and Associated Injuries

More than half of patients with frontal bone fractures have associated neurologic
injuries (Table 1).2 These injuries can vary widely from loss of consciousness to intra-
cranial bleeding. Up to 10% of patients with frontal fractures have subdural or epidural
hematomas that require immediate surgical intervention.7 CT evaluation of the head
and cervical spine should be considered essentially routine components of evaluation
in patients with frontal bone fractures.
Severe frontal fractures have the ability to extend into the temporal bones and
should prompt the emergency physician to evaluate the patient’s hearing and facial
nerve function. Obtaining temporal bone cuts on CT scan in patients with particularly
bad fractures may be beneficial, as true temporal bone involvement requires addi-
tional medications, warnings, and follow-up with an otorhinolaryngologist to evaluate
for associated hearing loss. Otorrhea in the setting of a temporal bone fracture should
also be considered a CSF leak until proven otherwise.
Ocular injuries are not uncommon when frontal sinus fractures involve the supraorbital
rim. In fact, up to 25% of people with frontal bone fractures have an ocular injury. In these
instances, injury to the globe itself (eg, globe rupture or laceration) or a vision-threatening
injury might be present and will need to be evaluated by an ophthalmologist. The most
542 Boswell

Table 1
Facial fractures and associated injuries

Fracture Type Common Associated Injuries Not to Miss

Frontal sinus Cerebrospinal fluid leak
Nasofrontal duct involvement/damage
Ocular injury
Neurologic injury
Zygomaticomaxillary Facial paresthesia
Oribtal apex injury: cranial nerve involvement
LeFort Dental or alveolar ridge fractures
Cerebrospinal fluid leaks
Severe epistaxis
Orbital Globe rupture or laceration
Visual field or acuity changes
Traumatic optic neuropathy
Optic nerve impingement
Extraocular muscle entrapment
Nasal Septal hematoma
Septal deviation
Septal mucosal injury
Epistaxis

commonly associated ocular finding is an afferent papillary defect, which is seen in about
10% of patients with a frontal sinus fracture.2
Another structure at risk for injury with frontal sinus fractures is the NFD. This duct is
located along the posteromedial floor of the frontal sinus, which composes the roof of
the orbit and drains the frontal sinus into the nasal passage, as stated previously. Frac-
ture of the posterior table or floor of the sinus can be associated with interruption,
obstruction, or complete disruption of the NFD, which will require surgical repair or
obliteration of the sinus cavity to ensure proper drainage to prevent mucocele and
mucopyocele formation.6
Approximately 6% of patients with frontal sinus fractures (regardless of the pres-
ence of CSF leak) will have a course complicated by the development of meningitis.
Fractures in the posterior table that involve the dura or are associated with CSF
leak brain injury increase the risk of meningitis. The risk is also increased in those
who have undergone surgical repair of their posterior table fracture and dura.8
The development of complications several years following the original injury is very
uncommon. When late complications do emerge, they can be potentially life threat-
ening. This scenario should be considered in the differential diagnosis when assessing
patients with a history of frontal sinus fracture. Late complications can include
cavernous sinus thrombosis, mucopyocele and mucocele, brain abscess, and
encephalitis. Recurrent surgical intervention might be required.

MIDFACE FRACTURES
Zygomaticomaxillary Complex Fractures
Anatomy
The zygomaticomaxillary (ZMC) complex is a quadripod composed of the lateral and
inferior orbital rims, the zygomatic arch, and the zygomaticomaxillary buttress. Given
that 2 of the 4 “legs” of the quadripod are part of the orbital structure, the ZMC is impor-
tant in maintaining the integrity of orbital volume and contents. Several buttresses are
incorporated in the ZMC: the zygomaticomaxillary buttress, the zygomaticotemporal
 Management of Facial Fractures 543

buttress, and the zygomaticofrontal buttress. These are points of articulation between
facial bones that are common sites of fracture. These articulation points, or sutures, are
inherently weak, resulting in an increased likelihood of fracture at these sites. Fracture
patterns have been defined differently in many classification schemes. The most widely
used is the scheme created by Zingg and colleagues,9 which divides the fracture
patterns into types A, B, and C and contains subtypes depending on the number of
components fractured and the severity/displacement of the fractures (Table 2).
Although many classifications exist, few are truly clinically relevant and are often
used more for research and for clarity of physician communication.

Epidemiology
As is common with most facial bone fractures, most ZMC fractures occur as a result of
motor vehicle crashes, assaults (via direct blows to the cheek bone), falls, and sporting
incidents. Injuries are more common in men than women and occur most often in
people between the ages of 20 and 41 years. Alcohol is involved approximately
35% of the time.10

Diagnosis and management

Significant swelling, ecchymosis, and pain are the most common presenting
complaints and findings in a patient with a ZMC fracture. Several physical signs
revealed by examination should heighten the physician’s suspicion of a fracture to
the ZMC complex. Enophthalmos, or an otherwise malpositioned globe, because of
orbital fracture is common, as is subconjunctival hemorrhage. Deformity may be
present as palpable emphysema or step-offs over any aspect of the complex, but it
is often obscured by the degree of swelling over the cheek or in the periorbital region.
The inferior orbital nerve tracks through the orbital floor, so in the setting of a ZMC
fracture, evaluation of sensory deficit in the regions of the ipsilateral cheek, inferior
eyelid, nose, and upper lip can demonstrate paresthesia or hyperesthesia if the nerve
is entrapped or damaged. Documentation of paresthesias by the emergency physi-
cian is crucial because 70% to 90% of them are permanent.11 Diplopia is a common
symptom if the extraocular muscle is entrapped. An ocular evaluation is imperative,
because almost any ocular or sensory complaint can be justified.
CT is the imaging modality of choice for ZMC fractures, given the variability and
combination of fracture patterns that can occur. CT allows the physician to evaluate
globe, nerve, and extraocular muscle involvement. Three-dimensional reconstructions
can be helpful when evaluating displacement of the fractures in addition to offering
surgeons a clearer idea of the severity of the injuries.
Alternatively, some clinicians suggest that plain radiographs, including a Waters,
a Caldwell, and an underexposed submental view, can provide sufficient information
to make the diagnosis. Given the availability and improved quality of CT scans, they
are more reasonable and practical to obtain than plain radiographs.
The structural integrity and prominence of the zygomatic bone make it an important
aspect of the facial structure. Fractures that are minimally or nondisplaced and are not

Table 2
Zingg zygomaticomaxillary fracture types

Type A Incomplete fractures

 Isolated lateral orbital rim
 Isolated inferior orbital rim
Type B Classic tetrapod fractures or simple malar fractures (noncomminuted)
Type C Comminuted fractures
544 Boswell

comminuted can usually be managed without surgical intervention; however, all frac-
tures of the ZMC complex should be evaluated by a facial surgeon. For ZMC fractures
that are comminuted or displaced, open reduction is the treatment of choice, with the
goal being to reduce the displacement and restore the facial structure. Additional
factors that may lead to surgical repair include involvement of the orbital floor and/
or the orbital apex. Fractures of the orbital floor alter the volume within the orbital
structure and can be outwardly appreciated as enophthalmos. The orbital apex is
the region of the orbit that surrounds the optic nerve and is in close approximation
to the internal carotid artery and the cavernous sinus. Fractures in the orbital apex
can lead to several other significant injuries, including damage to the internal carotid
artery or cavernous sinus or compromise of any of the cranial nerves that run within the
cavernous sinus in addition to direct damage to the optic nerve itself. Realignment of
a single aspect of a comminuted fracture does not ensure the remainder of the
complex is reduced properly. Even slightly misaligned fractures can lead to asymme-
try in the face and poor cosmetic results; thus, it is important for the emergency physi-
cian to involve a facial surgeon early. It is not uncommon, however, that surgical
intervention and repair will be delayed for several days to allow swelling to diminish.

Complications and associated injuries

One associated injury that should induce clinical concern is fracture to the orbital apex
with cranial nerve compromise (see Table 1). CT scans can demonstrate the involve-
ment of the apex, as well as identify comminuted bone impinging on the optic nerve. In
addition to direct compromise of the optic nerve, cranial nerves II, III, IV, V1, and VI all
are in close proximity to the apex and can be damaged by fracture to this structure,
making a full cranial nerve examination essential in the evaluation of ZMC fractures.12

LeFort Fractures
The LeFort fracture classification was named after a French surgeon, Rene LeFort,
early in the twentieth century. LeFort studied blunt facial trauma by applying different
magnitudes of force and angle to the faces of cadavers. LeFort fractures are usually
caused by direct blows to the face and are divided into 3 progressively severe cate-
gories, as described later in this article. In real life, fracture patterns are rarely consid-
ered “classic” LeFort fractures, but the classification and terminology are still used to
describe midface fractures. Each type describes a series of fractures commonly seen
in a pattern rather than a single, isolated fracture.

Anatomy
The 3 types of LeFort fractures can occur in any combination and can be unilateral,
bilateral, or both. By definition, all types of LeFort fractures involve a fracture of the
pterygoid plates. The absence of a pterygoid fracture rules out a LeFort fracture,
but the presence of a pterygoid fracture does not specifically imply a LeFort fracture
exists. If a pterygoid fracture is noted on CT scan, the emergency physician should
have a high index of suspicion for a LeFort-type injury.
LeFort I fractures are horizontal fractures of the maxilla, above the dental structures,
and involve the inferior nasal aperture. The fracture extends through the maxilla below
the ZMC junction. This constellation of fractures results in a separation the upper jaw
from the remainder of the face, sometimes referred to as a “floating palate.”
LeFort II fractures involve all of the boney components in a LeFort I, but rather than
being a horizontal-type fracture, it is more of a pyramidal shape that extends upward
to incorporate a fracture of the zygomaticomaxillary buttress, through the orbital floor
and inferior orbital rim into the medial orbital wall and posteriorly into the nasal septum.
 Management of Facial Fractures 545

As the fracture courses through the maxilla and zygoma, it continues through the
upper aspect of the pterygoid plates. The nasal complex and maxilla are divided
from the rest of the face.
In LeFort III fractures, the naso-orbital ethmoid complex, zygomas, and maxilla are
separated from the cranium. The fracture pattern extends from the nasal bridge down-
ward through the orbit (involving the medial and lateral walls and the floor) and
continues through the zygomaticofrontal buttress, thereby including the entire zygo-
matic arch, causing complete dissociation of the facial structure from the cranial
base. For this reason, type III LeFort fractures are also called craniofacial separation
or craniofacial dysjunction.
There can be multiple types of LeFort fractures on one side of the face and none on
the other, or there can be a variety of types on each side of the face. The presence of one
type of LeFort fracture on one side of the face does not indicate there is a LeFort fracture
on the other. However, in the setting of facial trauma severe enough to cause a LeFort
fracture of any type, the remainder of the boney facial structure should be evaluated for
additional fracture patterns, including ZMC and naso-orbital ethmoid fractures.

Diagnosis and treatment

The physical examination findings for each fracture type vary from the others. Physical
findings can include a swollen upper lip and a characteristic grating sensation when
the hard palate is manipulated, which are commonly seen in type I fractures. Impacted
maxillary fractures may not demonstrate mobility, but there may be a grating sensation
with attempted movement of the hard palate.
Type II fractures often have more significant deformity and swelling associated with
them. Telecanthus (widening of the intercanthal space) is often noted owing to the
location of the nasal septum fracture. Subconjunctival hemorrhage and infraorbital
ecchymosis can be bilateral, and mobility of the maxilla and hard palate is appreciable.
Type III fractures boast the most significant clinical findings. Significant mobility of
the entire facial structure is noted with manipulation. As with the other types, signifi-
cant facial swelling, deformity, and orbital ecchymosis are almost always present.
Associated with severe type II and usually with type III is the “dishface deformity,”
which is elongation and flattening of the facial structure.
Because fracture types can be found unilaterally, mobility of the face should be
tested on both sides as well as in the midline. Sensory deficits in the infraorbital region
extending inferiorly to the upper lip can be noted with type II fractures because the
fracture pattern involves the inferior orbital rim and floor. The inferior orbital nerve
runs along these structures and can easily be affected by fractures. Any deficits
should be noted and documented appropriately.
Again, CT scan is the imaging modality that is required to fully and adequately
assess the extent of boney and soft tissue injury. Plain films are not sufficient to assess
the degree of fracture patterns and displacement. In addition, plain films will not be
able to assess associated soft tissue injury.
Involving a facial surgeon early on is always a good idea when assessing a patient
with severe facial trauma. The presence of a LeFort fracture is an indication for surgical
repair. Lasting cosmetic and functional deficits result from conservative management;
the ultimate goals of surgical intervention are to restore the facial projection and the
involved sinus cavities and to reestablish proper occlusion of the teeth.

Complications and associated injuries

Epistaxis is commonly associated with LeFort type II and III fractures (see Table 1).
The location of the bleeding (anterior or posterior) and its severity will drive the
546 Boswell

decision-making process toward or away from nasal packing. The treatment of choice
for severe, life-threatening epistaxis is nasal packing. It is always safer to pack both the
posterior and anterior aspects of the nose to obtain hemostasis as rapidly as possible.
Life-threatening hemorrhage occurs in 1% to 11% of patients with facial fractures.13 It
is logical to consider catheter-based methods to achieve hemostasis after basic
measures, including packing, have been attempted and failed. Published case reports
indicate that transcatheter arterial embolization is being used more frequently to treat
intractable hemorrhage and has a reported success rate between 87% and 100%.13,14
Alveolar and palatal fractures are commonly associated with all types of LeFort frac-
tures and add an element of complexity to the surgical repair. Both types of additional
fractures can affect occlusion of the patient’s teeth. One of the primary goals of surgical
intervention begins with proper occlusion, and proper repair cannot be obtained
without good occlusion. If proper occlusion is not obtained, long-term complications
with bite are common.
CSF leaks are also frequent complications of primarily type II and type III fractures.15
CSF rhinorrhea can easily be obscured in the acute setting secondary to epistaxis, but
the astute emergency physician should have a high index of suspicion for this compli-
cation. As indicated before, assessment for the presence of b-2 transferrin can be
requested from the laboratory to confirm the diagnosis of CSF leak. In the presence
of a leak, neurosurgical consultation should be obtained early. Antibiotic prophylaxis
in the setting of CSF leak remains controversial and should be used at the discretion of
the treating neurosurgeon. Treatment with antibiotics should be aimed at broad
coverage, which includes the nasal flora.

ORBITAL FRACTURES

Trauma to the eye(s) and periorbital region are common complaints in the emergency
department. In fact, approximately 3% of emergency department visits are for trau-
matic injuries to the eye. A spectrum of injuries and disease processes accompanies
these complaints, with some being vision threatening (eg, globe rupture) and others
being benign (eg, laceration to the eyebrow). Orbital fractures can be associated
injuries that go along with any aspect along the spectrum. Orbital fractures rarely
require emergent surgical repair, but additional injuries that do need to be emergently
addressed are often present.
Most orbital fractures occur in men between the ages of 21 and 30 years and are the
result of assaults and motor vehicle collisions.16 In the setting of orbital trauma, it is easy
to understand why 22% to 29% of orbital fractures are associated with ocular injury.17

Anatomy
The structure of the orbit is created by bones of several thicknesses, arranged in
a conical shape. Traditionally, the orbit is thought of as a 4-walled structure with
a posterior apex. The optic nerve courses through the apex of the cone intracerebrally.
The orbital structure is a volume-containing structure that, when fractured, loses its
integrity and ability to maintain its volume, often resulting in enophthalmos and
compromise to the function of the extraocular muscles.
The frontal bone constitutes part of the superior orbital rim and orbital roof, which
contributes the thickness and therefore strength of these 2 structures. The adjoined
zygoma and the greater wing of the sphenoid bone make up the lateral wall of the orbit,
which is comparatively stronger than its floor and medial wall. The zygoma and maxil-
lary bones create the orbital floor and inferior rim. And, last, the medial wall of the orbit is
composed of the ethmoid bone, specifically the very thin-walled lamina papyracea.
 Management of Facial Fractures 547

There are 2 categories of orbital fractures, pure and unpure, which are also known
as blowout fractures and orbital fractures, respectively. Blowout fractures involve only
the orbital walls and spare the superior, lateral, and inferior rims. These are usually the
result of sudden pressure changes within the orbit, which cause fractures on the
thinner and weaker orbital walls, and account for approximately 11% of all orbital frac-
tures.18 Pure (orbital) fractures can involve any combination of the orbital walls but also
involve a fracture of at least 1 of the 3 orbital rims. Orbital fractures are commonly
caused by direct forces on the periorbital area. It is not uncommon for orbital fractures
to be associated with other patterns, including ZMC, LeFort, and naso-orbital ethmoid
fractures. Multiple facial fractures or fracture patterns should alert the emergency
physician to the severity of the injury, as they are high-force injuries and can be asso-
ciated with higher complications, higher rates of concomitant injuries, and a greater
likelihood of requiring extensive surgical repair.

Diagnosis and Treatment

Once a patient has been stabilized, facial injuries can be evaluated. Patients with peri-
orbital trauma usually have swelling, ecchymosis, bleeding, and pain. Specifically in
orbital trauma, several key areas of evaluation cannot be missed: the globe, pupillary
response, extraocular movements, and visual acuity. As previously mentioned, if there
is any concern about globe rupture or laceration, the eye should be covered in a fashion
that prevents any pressure from being placed on it, and the remainder of the evaluation
should be placed on hold until the eye can be assessed by an ophthalmologist. Without
indication of globe rupture or laceration, the initial eye examination should start with
simple observation of the facial structure. Swelling, obvious deformity, and/or malpo-
sitioned globes (eg, appreciable enophthalmos or exophthalmos) can be useful pieces
of information. Palpation of the surrounding boney structures can reveal step-offs, rep-
resenting obvious fracture, and crepitus, representing subcutaneous emphysema,
from a fractured medial or inferior orbital wall with communication into the ethmoid
or maxillary sinuses, respectively. Visual acuity and fields should be assessed before
any direct manipulation of the globe, using a basic Snellen chart. Color perception
(including changes in hues) can be difficult to assess, especially in patients who are
color blind, but evaluation should be attempted. The presence of binocular diplopia
can represent extraocular muscle dysfunction, entrapment, or compression caused
by hematoma or swelling. Regardless of the cause of diplopia, it is abnormal and should
be considered a result of trauma requiring further evaluation. The globe should be
examined for foreign bodies and retained contact lenses (which should be removed).
Obvious injuries to the globe, conjunctiva, or lids should be noted. Fluorescein should
be used to assess for corneal abrasion or irregularities. Pupillary response, both
efferent and afferent, needs a full assessment. Any abnormality, especially an afferent
defect, is grounds for ophthalmologic evaluation, as this indicates injury, which may be
ongoing, to the optic nerve. If hyphema is present, it should be documented. Extraoc-
ular movements should be examined carefully. The inability to demonstrate full range of
motion in all directions, thereby using all extraocular muscles, suggests muscle injury or
entrapment. Extraocular muscle entrapment is a clinical diagnosis based on restricted
range of motion, but CT scan can demonstrate herniated muscle through the fracture
line, which can assist in confirming the diagnosis. Patients with entrapped muscle often
have associated vagal-type symptoms, including nausea, vomiting, or syncope.
CT scans of the facial bones once again constitute the imaging study of choice.
Coronal and sagittal images are beneficial to emergency physicians and facial
surgeons in determining the degree of boney displacement and involvement of the
apex or in assessing entrapment of the extraocular musculature (Fig. 1).
548 Boswell

Fig. 1. Blowout fracture with muscle entrapment. Coronal CT scan showing linear trapdoor
fracture (arrow) of orbital floor. (From Gerbino G, Roccia F, Bianchi FA, et al. Surgery for
orbital trapdoor fracture. J Oral Maxillofac Surg 2010;68(6):1310–6; with permission.)

Indications for surgical intervention as well as its timing remain controversial. Few
orbital fractures mandate emergent intervention. True entrapment of the extraocular
musculature within the fracture (including pediatric “trapdoor” fractures [see later in
this article]) is an emergent problem, which requires intervention to prevent lasting
deficit.19 Additionally, fractures to the apex of the orbit that result in clinically apparent
deficits (eg, traumatic optic neuropathy) or yield radiologic findings that induce concern
should undergo urgent operation to reduce pressure or impingement on the optic
nerve. Relatively strong indications for surgery include the following: large orbital floor
defects (>1 cm), enophthalmos, hypoglobus, or other malpositioning of the globe that
persists for weeks following the initial injury.20 Fractures that do not require surgical
intervention are typically managed conservatively. When surgery is indicated, it is
usually delayed until swelling and ecchymosis resolve, often in a week to several weeks.
Assuming the patient is stable and has no other injuries causing clinical concern,
and after consulting with a facial surgeon, it is often acceptable to discharge patients
home to follow up as an outpatient for possible definitive treatment. Patients should be
discharged with proper pain management. If fractures extend into the sinuses, the
patient should be sent home with “sinus precautions,” which include no nose blowing
or sneezing with the mouth open.
Complications and Associated Injuries
Traumatic optic neuropathy is the loss of vision, visual fields, or color perception in the
setting of periocular trauma and is an indication of direct optic nerve trauma (see
Table 1). Any change in perception of color or vision loss should be a sign of great concern
to the emergency physician, as vision loss can, and often does, become permanent.
Extraocular muscle that is entrapped can easily become ischemic. Prolonged
ischemia can lead to muscle damage and long-term impairment in mobility. A “trap-
door” fracture, described within the pediatric population, is a fracture of the orbital
floor, in which the bony fragment forms a greenstick fracture after initial displacement,
entrapping the inferior rectus muscle. These fractures are often difficult to diagnose,
as the orbital volume is maintained and the only symptom may be restriction of ocular
movement.

NASAL FRACTURES

The nasal bone is the most commonly broken bone of the face, likely because of its
prominence.21 Like other facial fractures, nasal fractures are usually the result of motor
 Management of Facial Fractures 549

vehicle collisions, assaults, sports incidents, or falls, and often present with swelling,
pain, and ecchymosis.

Anatomy
The nasal bone is a pyramidal structure composed of 2 thin bones that become
progressively thinner the more distally they project. The most distal aspect and the
tip of the nose are composed of cartilage, which is relatively resistant to injury. The
more proximal aspect of the nasal bone is thicker and adjoins to the ethmoid bone
and the maxilla. The more proximal nasal fractures can extend into the maxilla and
ethmoid bone, creating a naso-orbital ethmoid fracture, as previously described.

Diagnosis and Treatment

Nasal fractures can be isolated injuries, or they can be a single fracture among other
facial injuries. Patients often have swelling, bruising, epistaxis, infraorbital ecchymosis,
and pain. There often is a noticeable deformity to the nasal bridge, but swelling some-
times precludes the ability to appreciate it. The physical evaluation of a patient with
a suspected nasal bone fracture should include an external examination as well as an
internal examination. The external examination should focus on palpation of the nasal
bridge for deformities or tenderness in addition to the presence of possible sensory
deficits that may indicate additional facial fracture or injury. A properly performed
internal examination involves a nasal speculum or otoscope, proper analgesia/anes-
thetic, and an inhaled vasoconstrictor. The patient’s nasal passages should be anes-
thetized with topical lidocaine (4%), and an aerosolized vasoconstrictor should be
used to help stop oozing and prevent bleeding during the examination. The examination
should focus on the septum, looking for deviation, mucosal injury, and/or hematoma.
When an isolated nasal fracture is suspected, plain radiographs are adequate for
diagnosis. The presence of additional facial injuries or other findings that raise concern
should encourage the emergency physician to pursue more detailed imaging in the
form of a CT scan. The CT scan will properly identify concomitant fractures or soft
tissue injuries in addition to the nasal fracture.
A simple nasal bone fracture can be easily treated with ice for swelling, pain control,
and time. Comminuted or open fractures require more consideration regarding proper
treatment. Patients who present immediately after injury often have not developed
substantial swelling, which provides the best window of opportunity to assess the
deformity and perform a closed reduction of the fracture. Once swelling develops,
deformities are obscured, so waiting several days to a week for the swelling and
pain to dissipate is a reasonable treatment plan. In these instances and barring addi-
tional injuries preventing discharge, patients should be sent home with pain medica-
tions, sinus precautions, and antibiotics if they have open wounds. As with any degree
of swelling, elevation and ice are recommended. Referral to a facial surgeon for follow-
up within 1 week for evaluation and definitive treatment is appropriate.22

Complications and Associated Injuries

Several physical examination findings, even in a patient with an isolated nasal bone
fracture, should not be missed by the emergency physician (see Table 1). Septal hema-
tomas are easy to diagnose and treat. Appropriate treatment can prevent complica-
tions, such as septal hematoma infection and/or abscess or necrosis of the septal
cartilage with formation of a septal perforation. Straightforward incision and drainage
or clot removal from the hematoma with subsequent anterior nasal packing to prevent
reaccumulation of the hematoma can prevent these complications from occurring.
550 Boswell

Epistaxis is an obvious and frequent complication of nasal fractures. Generally

speaking, hemostasis has usually occurred by the time the patient presents to the
emergency department, but epistaxis can continue, thus requiring physician interven-
tion. Anterior bleeding from Kiesselbach plexus is common and generally easy to
control. Posterior nasal hemorrhage usually originates from the anterior ethmoidal
and sphenopalatine arteries and can be more difficult to control. Occasionally, place-
ment of packing (anterior or posterior, depending on the location of the hemorrhage) is
required to stop the bleeding. Patients who are discharged with nasal packing in
place, for any reason, should be given a prescription for antibiotics that cover gram-
positive organisms to prevent infection in addition to strict follow-up instructions for
packing removal and further treatment.
Open nasal bone fractures are not uncommon and need additional attention to
ensure proper follow-up and prevention of complications. As for all nasal fractures,
a thorough physical examination of the nose should be performed and any lacerations
should be well irrigated (especially if the injury was caused by a contaminated or soiled
object) and sutured closed. Any laceration internally or externally near the site of the
fracture should be considered an open fracture, so prophylactic antibiotics should
be prescribed.
Copious amounts of clear nasal secretions in a patient with nasal trauma or fracture
should prompt the emergency physician to be concerned about a CSF leak. Most CSF
leaks can be managed conservatively and resolve spontaneously, but leaks that
persist beyond 10 to 14 days should be assessed for possible repair of the dural
tear causing the leak.

SUMMARY

Facial trauma is a common complaint in the emergency department. Interventions can

range from simply diagnosing a fracture and providing referral, to very complex
management of severe fractures requiring stabilization of the airway, hemostasis of
active bleeding, and proper evaluation and management of many aspects of trauma.
It is vital that emergency physicians recognize associated injuries, including those
affecting the brain and cervical spine, as common associations in facial trauma.
The emergency physician must always maintain a high degree of suspicion and
should evaluate all complaints of facial trauma thoroughly, because a missed injury
can threaten life or vision. A methodical and organized examination is paramount
for patient safety and the physician’s documentation of the evaluation.
CT scans are the most efficient and comprehensive way to evaluate facial trauma
and fractures and should be used liberally in patients with any concern for soft tissue
or boney injury and especially in those who are unable to provide a reliable examina-
tion. CT scans of the head and cervical spine can be life-saving. Many injuries are
obscured by swelling or ecchymosis. It is always safer to consult a facial surgeon in
the setting of uncertainty. In patients who are safe for discharge, it is the responsibility
of the emergency physician to provide clear instructions regarding close follow-up.

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