AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Hippocrates described an array of facial injuries as long ago as 400 BC. In 1823, von Graeffe described an elastic tube placed in the nose to maintain an open airway. During the early 20th century, Sir Harold Gilles, father of plastic surgery, taught army personnel about breathing problems in patients with facial injuries and to place them supine to maintain an airway.

René Le Fort, a Frenchman, studied cadavers in 1901. He described 3 basic types of fractures. Endotracheal anesthesia and radiography developed during the First World War led to a better understanding and treatment of facial fractures. During the Second World War, a multidisciplinary approach to treatment of facial fractures continued to improve the outcomes of severely injured soldiers. Advent of CT reconstruction of facial bones, along with new surgical techniques, has dramatically improved the final appearance patients who have sustained bony injuries.

Pathophysiology

Maxillofacial fractures result from blunt or penetrating injury. Blunt injuries are far more common, resulting from vehicular accidents, altercations, sporting-related trauma, occupational injuries, and falls. Penetrating injuries mainly are the result of gunshot wounds, stabbings, and explosions.

Type of object striking the face and force behind the object are the main determinants of whether a person sustains soft-tissue or bony injury. In automobile accidents, striking a hard dashboard is more likely to cause bony injury than striking a padded dashboard or an airbag. Striking the steering wheel concentrates the force more than striking the flat surface of the dashboard. This also holds true for altercations with a bat, as compared to a bare fist or boxing glove. Penetrating injury from a shot gun at a distance is not likely to cause fractures. Bullets from low-velocity guns are likely to cause fractures; high-velocity bullets cause fractures and extensive soft-tissue damage.

The amount of force needed to fracture different bones of the face has been studied; injuries have been divided into those that require high impact to fracture (greater than 50 times the force of gravity [g]) and those that require a low impact to fracture (50 g or less).

• High impact
• • Supraorbital rim - 200 g
  • Symphysis of the mandible - 100 g
  • Frontal-glabellar bone - 100 g
  • Angle of mandible - 70 g
• Low impact
• • Zygoma - 50 g
  • Nasal bone - 30 g

Frontal bone and supraorbital fractures require high-energy impact. Forces this strong may indicate intracranial injury. Frontal bone contains the frontal sinus, and fractures of only the anterior (outer) table or both anterior and posterior (inner) tables are possible. Associated fractures of the supraorbital ridge, nasoethmoidal complex, and other facial bones also may occur (see Fractures, Face).

For more information, see Medscape's Trauma Resource Center.

Frequency

United States

Approximately 3 million facial injuries occur annually; however, most do not involve maxillofacial fractures. One study placed the incidence of severe maxillofacial injury (fractures and lacerations) at 0.04-0.09% for persons in motor vehicle accidents. Incidence of fractures due to motor vehicle injuries is higher in rural areas, and altercation-related fractures are more frequent in urban areas.

Mortality/Morbidity

Incidence of other major injuries is as high as 50% in high-impact fractures, while it is 21% for low-impact fractures. Motor vehicle accidents are more likely than violent altercations to cause other injuries. Mortality rate in high-impact fractures is as high as 12%, yet deaths rarely occur from maxillofacial injury. The incidence of cervical spine injuries associated with frontal fractures has been reported in the 0.2-6.0% range.

Sex

Adult male-to-female ratio is 3:1. Consider domestic violence in women with facial injuries not related to a motor vehicle crash.

Age

Male predominance is reduced to 2:1 in children. Consider child abuse when facial injuries are found in children.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Since maxillofacial fractures are the result of trauma, primary survey and attention to ABCs take priority. Focus initially on patency of airway, control of cervical spine, and whether the patient is having difficulty breathing, and determine if the patient is experiencing symptoms of shock or neurologic impairment.
• Once life threats have been addressed, obtain a thorough history.
• • Allergies
  • Medications
  • Medical history
  • Last meal
  • Events leading to injury
• Question patient about injury.
• • Does patient have epistaxis or clear fluid draining from nares or ears?
  • Did patient lose consciousness?
  • Has patient had any visual problems, such as double or blurred vision?
  • Has patient had any hearing problems, such as decreased hearing or tinnitus?
  • Do the teeth come together normally and is patient able to bite down without pain?
  • Does patient have areas of numbness or tingling on the face?
  • In women, ask if the injury was from a partner or if they feel threatened by anyone.
  • In children, ask questions to determine if child abuse is an issue.

Physical

• Complete exam of the face is necessary since multiple injuries can occur easily. Portions of the exam specific for the frontal bone are marked with an asterisk (*).
• • Inspect face for asymmetry, which is often easiest to do looking down from the head of the bed.
  • *Inspect open wounds for foreign bodies and palpate for bony injury.
  • *Palpate bony structures of the supraorbital ridge and frontal bone for step-off fractures.
  • *Examine eyes thoroughly for injury, abnormality of ocular movements, and visual acuity.
  • Inspect nares for telecanthus and widening of the nasal bridge. Palpate for tenderness and crepitus.
  • Inspect nasal septum for septal hematoma and clear rhinorrhea, which suggests cerebrospinal fluid (CSF) leak.
  • Palpate zygoma along its arch as well as its articulations with frontal bone, temporal bone, and maxillae.
  • Check facial stability by grasping teeth and hard palate, then gently pushing back and forth, then up and down, feeling for movement or instability of midface.
  • Inspect teeth for fracture and bleeding at gum line, a sign of fracture through alveolar bone. Test for stability.
  • Check teeth for malocclusion and step-off.
  • Palpate mandible for tenderness, edema, and step-off along its symphysis, body, angle, and condyle anterior to ear canal.
  • *Evaluate supraorbital, infraorbital, inferior alveolar, and mental nerve distributions for hypoesthesia and anesthesia.
  • Frontal fracture is suspected in patients who experience high-impact, blunt trauma and have a physical exam demonstrating step-off of the frontal bone or supraorbital ridge. Epistaxis or CSF leak merits further evaluation if the patient has a forehead injury.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Airway obstruction
Dental fractures
Foreign body aspiration, teeth
Nerve injury - Supraorbital, infraorbital, inferior alveolar, facial

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Direct lab studies toward workup of trauma patient.
• If fracture is an isolated injury, obtain preoperative labs if surgery is planned.

Imaging Studies

• Radiographs
• • Obtain routine facial views, including Waters, Caldwell, and lateral projections.
  • Caldwell projection provides the best view of the anterior table; however, the posterior table is difficult to assess in any of the standard plain film views.
• CT scan
• • Frontal sinus fractures usually require CT scan, examining bone windows to evaluate the posterior table of the frontal sinus.
  • Look for associated orbital rim and nasoethmoidal fractures on CT scan.
  • Consider brain CT scan to exclude brain injuries or intracranial bleeds.

Other Tests

• Test clear rhinorrhea for glucose to help determine if it is CSF, as nasal secretions are normally low in glucose.
• If blood is present, this test is unreliable.
• Blood-tinged fluid can be placed on filter paper to look for a double ring sign of CSF around blood; however, this is not reliable.

Procedures

• When dural leak causing CSF rhinorrhea is suspected yet cannot be proven, the following procedure, which is generally not performed in the emergency department, may be done. Inject fluorescein dye into the lumbar subarachnoid space. Examine the discharged nasal fluid 30 minutes later with a Wood lamp for fluorescence; fluorescence confirms CSF rhinorrhea.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

• ABCs are first priority. Hold airway open by chin lift, jaw thrust, or airway adjuncts, including endotracheal intubation.
• Because of concerns over intracranial placement of endotracheal tubes, avoid using the nasotracheal route for intubation if the patient has extensive facial damage or midface fracture is suspected.
• Place the patient on a backboard with a collar if cervical spine injury is a possibility.
• Treat hypoventilation with intubation and bag ventilation.
• Control actively bleeding wounds by applying a bandage with direct pressure.

Emergency Department Care

• ABCs take priority; reassess airway frequently.
• Do not focus solely on the obvious deformity, thereby failing to perform a complete primary survey.
• Rapidly diagnose other life threats and undertake appropriate resuscitation. Follow with a complete secondary survey.
• Diagnosis of frontal bone fracture in the ED is part of secondary survey.

Consultations

• If a frontal fracture is diagnosed, refer patient to a neurosurgeon, as these injuries often are associated with intracranial injury.
• Provide care for a patient with multiple injuries in conjunction with a surgeon experienced in trauma care.
• The incidence of posttraumatic stress disorder is high in patients with facial injuries, and a consultation with a psychiatrist should be considered.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

When airway control is needed, rapid-sequence induction is often the preferred method. Rapid-sequence induction utilizes medications to induce unconsciousness and muscle paralysis to facilitate intubation. A cricothyroidotomy kit should be at bedside in case problems arise.

Medication for pain control is appropriate, including NSAIDs, narcotics, or local anesthetics.

Use of prophylactic antibiotics is controversial when a CSF leak is identified. It is usually left to the discretion of the specialist assuming care of the patient.

In cases of open wounds, administer tetanus toxoid if the patient is not up to date.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

These drugs are used most commonly for relief of mild to moderately severe pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Drug Category: Analgesics

Pain control is essential to quality care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Drug Category: Immunoglobulins

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Drug Category: Toxoid

This agent is used for tetanus immunization. Booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Since these fractures require extreme force, admitting all except those few patients with isolated, nondisplaced anterior table fractures is appropriate.
• Patients with depression of the inner table often require neurosurgical intervention to elevate the fragment.
• Those with continued CSF leak may require a frontal sinus procedure involving ablation of the sinus and removal of the inner table to allow the frontal sinus to become part of cranium.

Transfer

• If appropriate specialists are not available, arrange transfer to a higher level hospital. Regulations of the Emergency Medical Treatment and Active Labor Act (EMTALA) must be followed.

Deterrence/Prevention

• Use of seat belts and airbags can reduce incidence of facial injuries in motor vehicle accidents. Use of helmets with facial guards can reduce injury in motorcycle accidents and in such sports as skiing, snowboarding, hockey, and football.

Complications

• CSF leaks may continue, though most cease by 2-3 weeks after the injury.
• Observe patient closely for signs and symptoms of meningitis or abscess formation.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Facial Fracture.
• Patients should be made aware of the high incidence of posttraumatic stress disorder in facial injuries and have resources available should symptoms occur.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to diagnose frontal fracture
• Failure to diagnose associated intracranial or cervical spine injuries because focus was on obvious injury

Special Concerns

• Always consider loss of airway and intracranial and intraabdominal injury.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Glynn SM, Asarnow JR, Asarnow R, et al. The development of acute post-traumatic stress disorder after orofacial injury: a prospective study in a large urban hospital. J Oral Maxillofac Surg. Jul 2003;61(7):785-92. [Medline].
• Hendler BH, Rosen P. Maxillofacial trauma. In: Rosen P, ed. Emergency Medicine: Concepts and Clinical Practice. Mosby-Year Book; 1998:1093-1103.
• McGill J, Ling L, Taylor P. Facial trauma. Diagnostic Radiology in Emergency Medicine. Mosby-Year Book; 1992:51-76.
• Smith RG. Maxillofacial injuries. In: Harwood-Nuss A, ed. The Clinical Practice of Emergency Medicine. Lippincott Williams & Wilkins Publishers; 1991:337-43.
• Snell RS, Smith MS. The face, scalp, and mouth. In: Clinical Anatomy for Emergency Medicine. Mosby-Year Book; 1993:206-241.
• Spoor T, Ramocki JM, Kwito GM. Ocular trauma. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. Lippincott, Williams & Wilkins; 1996:225-41.
• Sullivan W. Trauma to the face. In: Wilson RF, Walt AJ, eds. Management of Trauma: Pitfalls and Practice. Lippincott, Williams & Wilkins; 1996:242-69.
• Thomas SH, Shepherd SM. Maxillofacial injuries. In: Harwood-Nuss A, ed. The Clinical Practice of Emergency Medicine. Lippincott, Williams & Wilkins; 1996:408-18.
• Hasan N, Colucciello SA. Maxillofacial trauma. In: Tintinalli JE, Gabor KD, Stapczynski SJ, eds. Emergency Medicine: A Comprehensive Study Guide. 6^th ed. McGraw-Hill Co Inc; 2004:chap 257, p1583-1590.
• McKay MP. Facial trauma. In: Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine, Concepts and Clinical Practice. Vol 1. 6^th ed. Philadelphia, PA: Mosby Elsevier; 2006:382-98/chap 39.

Article Last Updated: Mar 6, 2008