Evaluation and management of facial fractures

Evaluation and management of facial fractures

Jeffrey S. Carithers

Fractures of the facial skeleton, most commonly caused by high-speed motor vehicle accidents, assaults and sports mishaps, are being encountered with increasing frequency in emergency departments. Such injuries require rapid initial evaluation and treatment, since they may involve airway obstruction or other life-threatening conditions that are not immediately obvious.

The management of facial fractures has several phases. The first priority is to address immediate problems in accordance with Advanced Trauma Life Support guidlines. A search for other intracranial, cervical spine, chest, abdominal and extremity injuries should be performed in the secondary survey.[1] After the patient is stabilized, a more thorough examination of facial injuries is performed and a treatment plan is initiated. If depressed or displaced facial fractures are present or if the patient has facial lacerations that may leave scarring, consultation with a facial plastic surgeon or otolaryngologist experienced in trauma repair may be advisable.

Evaluation and management of facial fractures requires knowledge of the anatomy, treatment methods and potential associated injuries for each type of facial fracture. Facial fractures include the maxilla, nose, nasofrontal-ethmoidal complex and orbit and zygomatic complex. Mandibular fractures are beyond the scope of this article.

Immediate Treatment

In a patient with a maxillofacial injury, the primary concern is to secure a stable airway, since a posteriorly displaced fractured mandible, displaced soft tissues, blood, secretions or other foreign material may obstruct the airway and cause asphyxia. The mouth must be examined immediately, and any loose, foreign material such as dentures, food, fractured teeth or bone fragments should be removed. Obstructing blood dots or saliva should be removed with gentle suction.

If cervical spine injuries have been ruled out, and if no other injuries necessitate a supine position, the patient should be placed in the semiprone position to allow drainage of blood and secretions from the airway. When upper airway obstruction occurs as a result of loss of mandibular support or severe edema of the tongue and pharyngeal tissues, it may be possible to re-establish the airway by protracting the tongue with a heavy suture or towel clip. An oral or nasal pharyngeal airway device if no evidence of upper or midfacial injury is apparent) can be introduced to maintain air flow until a more secure airway is achieved.

Nasal hemorrhage may be controlled with intranasal balloons or packing techniques, but these measures should be avoided if there is a possibility of concurrent intracranial or midfacial injury. Endotracheal intubation or, as a last resort, cricothyroidotomy should be performed promptly in patients with a compromised or deteriorating airway resulting from upper airway obstruction. Action should be taken as quickly as possible to prevent a more pressured (and possibly less successful) intubation.


Good preparation is vital when performing endotracheal intubation in traumatized patients. All necessary instruments must be tested and placed within reach. Essential equipment includes a laryngoscope with a working fight, a rigid suction device, several sizes of endotracheal tubes, a syringe to inflate the endotracheal tube cuffs, a ventilation system and oxygen. An intravenous line is vital in case it becomes necessary to administer a sedative, a muscle relaxant or a paralytic agent. Continuous electrocardiographic and pulse oximetry monitoring are useful but should not delay intubation.

Orotracheal intubation is generally preferable to nasotracheal intubation, since an orotracheal tube is placed more quickly and more reliably. The nasotracheal tube may also introduce a greater risk of additional midfacial or intracranial injury and should, therefore, be avoided in patients with extensive midfacial fractures. The endotracheal tube should be secured to the face with tape or, if injury to the facial soft tissue is extensive, secured to any stable dentition with a large suture.


Emergency cricothyroidotomy is indicated if an airway cannot be established by other means. Cricothyroidotomy is considered easier and much safer than tracheotomy in an emergency situation. To perform a cricothyroidotomy, the patient is placed in a supine position with the head hyperextended. The larynx is secured by bracing it in the midline with the fingers of the nondominant hand, and the soft cricothyroid membrane is palpated immediately inferior to the thyroid and superior to the cricoid cartilage.

In an emergency, time is not taken to administer local anesthesia. A small incision is made through the skin and down through the cricothyroid membrane until the airway is entered. The knife handle is then inserted through the incision and turned 90 degrees to establish an airway and to allow introduction of an endotracheal tube through the opening. Because an indwelling tube placed during a cricothyroidotomy procedure has a higher incidence of complications than a tube placed through tracheotomy, a tracheotomy should be performed at the earliest possible convenience.

Maxillary Fractures

The bone structure of the midface has evolved primarily to brace the maxillary dental arch against the masticatory forces of the mandible.[2] The structural support is based on several well-defined, vertically oriented paired buttresses (Figure 1). The nasomaxillary buttresses are the most anterior pair. The zygomaticomaxillary buttresses support the midportion of the maxillary alveolar process and are often referred to as the key ridge because they carry the g-reatest occlusal load. Posterior to the zygomatico-maxillary buttresses are the pterygomaxillary buttresses. Horizontally oriented struts consisting of thickened bone help support the vertical buttresses. Thin bone connects the sturdy vertical and horizontal elements and encloses the maxillary sinuses.[3]

Forces applied to the midfacial skeleton usually result in fairly characteristic fractures along horizontally oriented lines of weakness that were described by LeFort in 1901 (Figure 2). High-impact injuries such as those resulting from an automobile accident frequently create midfacial fractures with several different LeFort classifications (for example, a left-sided Lefort I with a right-sided LeFort II). More extensive, comminuted fractures may not fit any particular LeFort classification and therefore are termed “unclassified fractures.” Fractures of the alveolar ridge or palate may occur with unclassified midfacial fractures.

Patients with maxillary fractures generally present with symmetric facial swelling, periorbital ecchymosis (“raccoon eyes”), subconjunctival hemorrhages and flattening or elongation of the midface (Figure 3). The airway may be obstructed as a result of bleeding or edema of the soft palate. The maxillae may be stable if firmly impacted but more frequently are floating. The status should be evaluated by grasping and manipulating the maxillary incisors with one hand while bracing the other hand against the patient’s forehead to stabilize the head. Tapping the teeth with a metal instrument produces a “cracked pot” note if the maxilla is fractured. This technique is also diagnostic for maxillary fractures.[4] In addition, malocclusion is generally evident, as a result of malalignment of the facial bony structures.

In cases of LeFort II fractures, tenderness and irregularity of the infraorbital rims are present where the fracture passes. Anesthesia may be present in the infraorbital nerve distribution if this branch of the fifth cranial nerve has been injured. Tenderness over the zygomatic arch and superolateral orbital rim are frequently present with LeFort III fractures, and irregularity may be palpable through the overlying edema at these fracture sites.

A detailed evaluation is assisted by radiologic examination of the midfacial skeleton with survey films, but computed tomographic (CT) scanning (maxillofacial CT with axial and coronal views) is nearly always required to define the extent of the injury accurately. In some cases, three-dimensional CT reconstruction may provide an even clearer representation of the extent of injury and thereby facilitate repair plans after subspecialty referral.[5]

Treatment of maxillary fractures is directed toward restoring the zygomatico-maxillary and nasomaxillary buttresses to the anatomic positions to bring the maxillae into a proper occlusal relationship with the mandible.

Nasal Fractures

The prominent and exposed location of the nose makes it the third most commonly fractured structure.[6] Athletic injuries, childhood falls, assaults and motor vehicle accidents are among the numerous causes of nasal and nasal septal fractures. Proper management is important to prevent the dramatic functional and aesthetic deformities that may result from injury to the nose. Early consultation with a facial plastic surgeon or otolaryngologist may be indicated in cases of severe nasal fractures.

The framework of the nose consists of both bony and cartilaginous components Figure 4). The upper one third of the nose is supported by the paired nasal bones, the frontal processes of the maxillae and the nasal process of the frontal bone. The structural components of the lower two thirds of the nose are cartilaginous, making this region semimobile. The components of the cartilaginous skeleton are paired upper lateral cartilages that attach to the inner aspect of the nasal bones and a small portion of the frontal process of the maxillae. The paired alar cartilages support the tip of the nose, and the medial crura support the columella.

The force and direction of the nasal trauma generally determine the type of nasal fracture. A frontal blow fractures the inferior portions of the nasal bones in a transversely oriented plane. The more commonly occurring lateral blow may create a C-shaped deformity, with a concavity on the side of the injury and a contralateral convexity. Nasal septal fractures may occur without an associated fracture of the nasal bones. However, deviated fractures of the nasal bones are almost always associated with fractures of the nasal septum because of the key role of the septum in support of the nose.[7]

Frequent clinical findings in nasal fracture include epistaxis, swelling of the nasal dorsum, periorbital ecchymosis and subconjunctival hemorrhage, nasal tenderness and mobility, external deviation, and flattening or broadening of the nose. Examination of the internal nose should include suctioning of all dots and debris and vasoconstriction of the mucous membranes with epinephrine or phenylephrine spray if needed. A diligent search for evidence of a septal hematoma should always be performed because an unrecognized septal hematoma may strip the underlying septal cartilage of its vascular supply and progress to abscess formation, cartilage necrosis and loss of nasal support with resulting external deformity and septal perforation. Radiographic examination with special nasal views may be helpful in diagnosis and as a medicolegal record. The clinical examination, however, is the key to diagnosis because a high incidence of both false-positive and false-negative readings has been demonstrated with radiographic diagnosis alone.

Epistaxis from nasal trauma generally ceases spontaneously but may require the placement of intranasal packs. A septal hematoma should be drained as soon as possible through intranasal puncture incisions, followed by packing to prevent recurrence. Edema of the nasal dorsum may obscure an underlying bony nasal deformity that becomes apparent as the swelling subsides. Resolution of nasal edema is aided by application of ice packs and elevation of the patient’s head. Patients should be informed that although reduction of fractures can be performed immediately, repair is often delayed for four to seven days until the nasal edema subsides, thus allowing more accurate and cosmetic positioning of the bony fragments.

Nasal injuries in children deserve special consideration and early consultation. Septal hematoma is more commonly seen in children than in adults, and evacuation of the hematoma is necessary to prevent avascular necrosis of the septal cartilage, septal abscess and subsequent nasal saddle deformity.[8] Greenstick fractures are common in children, and diagnosis of these fractures may be difficult.

Fractures of the

Nasofrontal-Ethmoidal Complex

Fractures of the nasofrontal-ethmoidal complex are relatively rare but, when fractures of this region occur, other serious regional injuries frequently result because of the severe forces involved. The proximity of the brain and orbital structures necessitates accurate planning of evaluation and treatment.

The frontal bone consists of a vertical portion and a horizontal floor. The vertical portion creates the thick anterior wall and thin posterior wall of the frontal sinus. The frontal sinus is variable in size, asymmetric and divided by a median septum. The ethmoid sinuses and cribiform plates (olfactory areas of the nose) are just inferior to the frontal sinuses. The lateral walls of the ethmoid sinuses comprise portions of the medial walls of the orbits. Injuries to this nasofrontal-ethmoidal complex may range from a crack of the anterior frontal sinus wall to a crushing injury of the ethmoids and anterior and posterior frontal sinus walls with brain exposure and leakage of cerebrospinal fluid.[9]

Evaluation should include assessment for injury to the central nervous system and cervical spine. Considerable edema, soft tissue injury and epistaxis may be present, and leakage of cerebrospinal fluid may occur. Clear rhinorrhea or a halo effect of fluid on a sheet or gauze indicates cerebrospinal fluid leakage. A careful evaluation of cranial nerve function should be performed, including tests of visual acuity, extraocular muscle function, and supraorbital, supratrochlear and infraorbital nerve function.

Intercanthal distances should be measured, and the nasal and frontal contours should be palpated and inspected for irregularities. The medial intercanthal distance across the nose usually should equal the distance from the medial canthus to the lateral canthus of each eye. Deviation from this measurement may suggest nasofrontal-ethmoidal complex deformity. Routine sinus radiographs may demonstrate clouding of the ethmoid or frontal sinuses or bony irregularities, but CT scanning is necessary to accurately define the extent of injury in a patient with suspected nasofrontal-ethmoidal fractures.

The general treatment measures described at the beginning of this article should be instituted. The head of the patient’s bed should be elevated if cerebrospinal fluid rhinorrhea is suspected and if the patient’s general condition allows. Antibiotic prophylaxis should be started. Neurologic consultation should be obtained promptly. Treatment will be performed as soon as the patient’s neurologic condition is stabilized enough to allow general anesthesia. Zygomatic Complex Fractures

Fractures of the zygoma are the third most common fracture of the facial skeleton, with only nasal and mandibular fractures occurring more frequently As with other facial fractures, zygomatic injuries most commonly are caused by blows from fists or blunt weapons, sports injuries or motor vehicle accidents.

The zygomatic (malar) bone articulates broadly with the maxibary bone medially and forms the zygomatic arch (cheekbone) in its lateral articulation with the temporal bone. Superiorly, the zygomatic bone articulates with the frontal bone along the orbital rim, and together with the sphenoid bone it forms a large portion of the lateral orbital wall. Since the body of the zygomatic bone has considerable strength, blows of sufficient force generally create fractures at the articulations of the zygomatic bone with the surrounding bones rather than passing through the body The medial portion of a typical fracture involves the orbital floor and generally passes through the infraorbital foramen (containing the infraorbital nerve) and across the anterior surface of the maxilla. The typical fracture also involves the posterior maxillary sinus wall (Figure 5).

Clinical signs and symptoms include regional ecchymosis, edema and hypoesthesia or anesthesia in the infraorbital nerve distribution. Tenderness and step-off deformity may be palpable at fracture sites along the lateral superior orbital rim, the infraorbital rim and over the zygomatic arch. When displacement occurs, it is most often a downward and inward rotation that flattens the malar eminence on the involved side and causes lateral eye depression. Extraocular movements should be evaluated since impairment of upward gaze with resultant diplopia may occur. This is usually a result of edema and ecchymosis of the orbital floor tissues, but could also be due to ocular muscle entrapment if a concomitant orbital floor blowout fracture is present.

Trismus (decreased ability to open the mouth) may be caused by impingement of the displaced zygoma on the coronoid process of the mandible, but trismus also may result from regional soft tissue trauma and edema. A thorough ocular examination may reveal associated ocular injuries. Radiologic evaluation with thinsection CT of the facial bones is almost a necessity for evaluation of fractures in this area. Initial treatment focuses on pain control and reduction of edema with ice packs and elevation of the patient’s head until referral can be made. A nondisplaced zygomatic fracture does not require surgical intervention.[10] The patient should be informed that reduction of a displaced fracture may be performed immediately but is generally delayed for four to seven days to allow for resolution of the overlying soft tissue edema.

Orbital Fractures

The orbital walls are composed of a number of differ-ent facial bones and therefore are involved in a variety of regional fractures. A supraorbital rim fracture may be an isolated fracture or a component of a more extensive frontal sinus fracture. Fractures of the lateral orbital wall usually are associated with a fracture of the zygomatic bone, and medial orbital wall fractures occur with nasoethmoid fractures and medial blowout fractures. Zygomatic bone fractures and pure orbital blowout fractures involve the orbital floor (Figure 5).

The orbital floor blowout fracture primarily is related to increased hydraulic pressure and shearing forces along the orbital floor created by impact to the eye by a blunt object such as a fist or a ball. This force is transmitted through the globe to the surrounding tissues and causes a depressed fracture of a segment of the orbital floor. Fractured portions of the orbital floor that are displaced into the underlying maxillary sinus may be accompanied by adjacent soft tissues. If the inferior rectus musde is displaced sufficiently to impinge against the edges of the fracture, entrapment may occur, causing impairment of upward gaze and diplopia.

Inspection of the periorbital region reveals ecchymosis and edema. No infraorbital regulanty is caused by an orbital floor blowout fractur-e because the orbital rim is not involved. However, an orbital floor blowout fractur-e may be present in conjunction with other regional fractures, and an orbital rim step-off irregularity may be palpable. Infraorbital nerve dysesthesia or anesthesia is a finding in 95 percent of isolated orbital floor fractures because of the likelihood of damage to this nerve branch as it passes through the orbital floor.

The relative positions of the medial and lateral canthi should be evaluated, and the pupillary levels should be compared. Evaluation of extraocular motility may reveal impairment of upward gaze in the involved eye, with resultant diplopia. Enophthalmos may be present as a result of the increased volume of the orbit from inferior displacement of the orbital floor. The high incidence of associated ocular injuries mandates evaluation of every blowout fracture by an ophthalmologist.

Pupillary reactions to direct and consensual stimulation, as well as visual acuity, should always be assessed. Radiologic evaluation of the orbital floor with a Water’s projection may demonstrate a hemispheric opacity hanging from the roof of the maxillary sinus. This opacity may represent either an inferiorly displaced bone fragment or edema and hematoma, which are difficult to differentiate. CT scanning is necessary to determine the presence and degree of orbital floor disruption. The most complete evaluation of the orbital contents is obtained with both coronal and axial sections.


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[2.] Sicher H. Oral anatomy. Sicher H, Du Brul EL, eds. St Louis: Mosby, 1970:69-73.

[3.] Stanley RB Jr. concepts and classification of craniofacial trauma: biomechanical principles. Facial Plast Surg 1988;5:193-5.

[4.] Dawson RG, Fordyce GL. Complex fractures of the middle third of the face and their early treatment. Br J Surg 1953;41:254-68.

[5.] White DN. Multidimensional imaging in maxillofacial surgery. Facial Plast Surg 1988;5:197-206.

[6.] Murray JA, Maran AG, Mackenzie IJ, Raab G. Open v closed reduction of the fractured nose. Arch Otolaryngol 1984;110:797-802.

[7.] Gross CW, Johnson CQ. Nasal fractures. In: English GM, ed. Otolaryngology. Vol. 4. Hagerston, Md.: Harper & Row, 1985:1-15.

[8.] Moran WB. Nasal trauma in children. Otolaryngol Clin North Am 1977;10:95-101.

[9.] Duvall AJ 3d, Porto DP, Lyons D, Boies LR Jr. Frontal sinus fractures. Analysis of treatment results. Arch Otolaryngol Head Neck Surg 1987,113:933-5.

[10.] Karlan MS, Cassisi Nj. Fractures of the zygoma. A geometric, biomechanical, and surgical analysis. Arch Otolaryngol 1979;105:320-7.

The Authors

JEFFREY S. CARITHERS, M.D. is in private practice in facial plastic and reconstructive surgery in Des Moines, Iowa. Dr. Carithers received his medical training at the University of Iowa College of Medicine, Iowa City, and completed a residency in otolaryngology-head and neck surgery at Ohio State University College of Medicine, Columbus, and a fellowship in facial plastic and reconstructive sur-gery through the Academy of Facial Plastic and Reconstructive Surgery.

BRENTON B. KOCH, M.D. is serving a residency in otolaryngology-head and neck surgery at the University of Iowa Hospitals and Clinics, Iowa City. Dr. Koch received his medical training at the University of Iowa College of Medicine.

Address correspondence to Jeffrey S. Carithers, M.D., Carithers Facial Surgery P.C., 535 40th St., Des Moines, IA 50312.

COPYRIGHT 1997 American Academy of Family Physicians

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