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Facial Fracture

facial fracturesPatients with facial fractures not uncommonly present themselves to the emergency room following a sports injury, altercation, fall, or motor vehicle accident. The face is made up of multiple bones and has several weak spots where fractures tend to occur.

A facial fracture is a break in one of the several bones of the face, including the frontal bone, the maxillary bone, the orbital bone, the nasal bone, and the mandible. In some cases, more than one bone can be fractured. Facial bones do not fracture easily because they are so well connected to other bones in the face.

In this article:

What Are the Types of Facial Fracture?

A frontal sinus fracture occurs through the frontal sinuses, which are air-filled cavities that are connected to areas inside the nose. They thin the bone in that area so that the forehead is weak. Trauma to the forehead generally results in fractures through the thin frontal sinuses. When the bone is fractured in that area, it results in a dent in the forehead where the sinuses get pushed in. The area initially swells so that you don’t see the dent as much until the swelling goes down.

Treatment is surgical and involves pushing the dent back out and obliterating the sinus. If the frontal sinus is not completely obliterated, it will continue to build up mucus, creating a mass of sinus fluid called a “mucocele”. If this complication occurs, it can result in another surgery to remove the mucocele. Another complication is leakage of cerebrospinal fluid from the brain to the inside of the nose. This happens when the dura or covering of the brain is punctured.

Nasal fractures are extremely common. You can get it by being punched in the nose, a motor vehicle trauma, being struck by a door closing, or any other major or minor event. The nasal bone is the small bone protruding from the nose. It can get fractured easily. It usually requires no particular treatment and heals on its own. If the nasal septum is fractured, it can be displaced, which can require surgery to correct the deformity. If the bridge of the nose is crumpled, it is called having a “saddle nose” and this will need to be surgically corrected. The surgery can involve a closed reduction and splinting or open surgery, depending on the severity of the fracture.

A more severe fracture is the naso-orbital-ethmoid fracture. This happens when severe trauma occurs to the front of the nose and is common in automobile accidents.

The nose itself becomes crumpled along with the bridge and the area behind the nose. The inner walls of the eye sockets become fracture as well. It takes general anesthesia and internal surgery to put the pieces of the nose together. It often requires multiple procedures to fix the deformity. The inner corners of the eye can be displaced so that surgery is necessary to put the bone back in place.

The orbital fracture involves a fracture of the eye socket. The orbit is made from bone that forms a socket for the eye to rest in. Most commonly, this fracture occurs when a large object strikes the eye, such as with a punch in the eye or a baseball to the eye. The weakest part of the orbit is the floor of the eye socket. This kind of fracture is known as a “blow out fracture” because the floor of the orbit is blown outward into the maxillary sinus. A blow out fracture may not need to be treated if there is no displacement of the eye itself. If the eye socket is blown out, the eye may sink back in the head and require surgery to correct.

Cheekbone fractures are also called zygoma fractures. It involves the most prominent part of the face along with the nose and chin and therefore gets struck often in altercations or motor vehicle accidents. The face will look lopsided if this fracture is displaced and so it may need surgery. It usually needs surgery if there is a significant depression of the fracture or if there is the involvement of the orbit as well.

Surgery involves multiple small incisions and elevation of the bone where it is held in place with metal plates and screws.

Fractures of the upper jaw are called maxillary fractures. There are at least three types of maxillary fractures, including the LeFort I, LeFort II, and LeFort III fractures.

Of the three, the LeFort I fracture is the least serious and the LeFort III is the most severe type of maxillary fracture. These fractures all involve the teeth. With the fracture, the bite is abnormal so the person can’t chew properly. The teeth have to be wired together as part of the surgical repair of these types of fractures. The bones are generally held together by titanium plates and screws. The jaws may be wired for several weeks or the wiring may be removed shortly after the bones are successfully wired shut.

Lower jaw fractures, also called mandible fractures, are common injuries. Fractures of the mandible result in injuries to the alignment of the teeth so that the fracture needs to be repaired so as to fix the person’s bite. Incorrect placement of the teeth after the fracture is more common, partly because the mandible is often broken into several pieces and the bone is thicker than other facial bones. Infection following a fracture to the mandible is common. When the fractures are repaired, the teeth are wired together and then the bone is repaired with screws and plates. Then the wiring is removed and rubber bands are affixed to the front bottom and top teeth to keep the teeth in normal alignment.

Risk Factors for a Facial Fracture

The risk factors for facial fracture include risk-types of behavior like driving too fast and driving without a seat belt. People likely to engage in sports or in altercations are likely to get facial fractures. More facial fractures happen in males between the ages of 15 and 30. These are the type most likely to engage in risky behaviors.

Symptoms of a Facial Fracture

When a person comes into the emergency room with a possible facial fracture, they may have symptoms of tenderness and pain over the fracture site. The face may be numb or show swelling at the site of the fracture. If the fracture is occurring at the level of the nose or the central portion of the face, there can be difficulty breathing or swallowing. There can be blood or other types of fluid in the nose.

If the fracture occurs in the jaw bone or nearby parts of the face, there may be an abnormal bite or an inability to open the mouth altogether. Severe cuts or lacerations of the gums mean that the fracture is “open” and is prone to get infected. When the fracture becomes infected, the area becomes red, warm and can ooze pus from the lacerated or open areas.

Diagnosis of a Facial Fracture

The proper way to diagnose a facial fracture depends on the location of the fracture. For example, a nasal bone fracture may not even need to be x-rayed because nothing is done and the finding of tenderness to the tip of the nasal bone may be enough to diagnose the fracture even without x-rays.

If there is a suspected ethmoid fracture, the fracture is deep and high up inside the nose. This is not palpable from the outside and plain film x-rays often do not show the presence of an ethmoid fracture. For this reason, a CT scan of the face will find the ethmoid fracture and any other occult fractures of the facial bones.

The fracture of the mandible or jaw is often fractured in several places at once. One of the best ways to diagnose these fractures is via a Panorex x-ray system, which is actually a type of dental x-ray that can pick up on the features of the mandible or maxilla. It is a technique that is unfortunately not always available at smaller hospitals.

Maxillary fractures or midface fractures are often the results of car accidents. Unfortunately, they are almost always associated with other severe, life-threatening injuries. What this means is that the diagnosis of maxillary fractures is often delayed while the emergency team works on more serious injuries. Eventually, the diagnosis is made by plain film or CT scan of the face. It is also a good way to diagnose cheekbone or zygomatic fractures. Sometimes there need to be special films done especially of the zygomatic bone to see if there is more than one fracture in the area.

Orbital fractures or eye socket fractures can be diagnosed using plain x-ray films; however, a CT scan of the orbital bones can also nicely diagnose the problem. If the x-ray is suspicious for fracture but not clear, a CT scan can be done to get more data on the fracture.

If the temporomandibular joint is dislocated and possibly fractured, an x-ray can show the presence of the dislocated joint. If there is a possible fracture, a CT scan is a better diagnostic test for the problems.

Treatment of a Facial Fracture

The treatment of facial fractures depends on the location and severity of the fracture. For example, frontal fractures may be repaired after other things are treated if the anterior wall of the fracture only is injured. If the posterior wall is a fracture, the patient needs immediate neurosurgical treatment. Besides surgical repair, the patient may need to have prophylactic antibiotics at the time of surgery in order to prevent meningitis and encephalitis.

In an orbital fracture, you can support the patient with pain relievers and ice, along with elevation of the head. You may not need surgery unless there is double vision after two weeks of healing. If the fracture is large or if the eye has sunken within the orbit, surgery is anticipated. If there is inferior rectus muscle entrapment into the maxillary sinus, surgery using a maxillofacial surgeon should be performed within 24 hours after the injury.

Nasal fractures often don’t need to be repaired surgically. A doctor can exert firm pressure on the sides of the nose to realign the nasal septum. A soft probe can be used to move the septum into place. There often needs to be control of nasal bleeding with ice and analgesia. It is best to do surgery on these fractures within one to two hours of the injury. Alternatively, you must wait for 10 to 14 days in order to wait until the swelling has gone down. Open wounds need antibiotics to prevent infection.

With zygomatic fractures or zygomaticomaxillary fractures, there needs to be open reduction and internal fixation (surgery) to repair the fracture, using plates made of titanium and screws. Small incisions are made around the injury in an area where the incisions won’t be so obvious. Then the indented parts are drawn out to normal and plates/screws are used to keep the fracture in place.

LeFort fractures of the maxillary bones are almost always treated with open surgery and internal fixation with screws and plates. If there is CSF in the nasal discharge, a neurosurgeon should be notified. Antibiotics are necessary if the fracture extends into the nose, the sinuses, or the area that holds the tooth.

In mandibular fractures, patients need admission to the hospital. Often multiple fractures are present in the mandible. These need open reduction and internal fixation. Because of the fact that the teeth and mouth are involved, there need to be antibiotics to prevent infection. Penicillin and clindamycin are common antibiotics used for prophylaxis.

Complications of Facial Fractures

Facial fractures are rarely life-threatening to the patient’s life but they are often connected to dangerous injuries to other body areas and blockage of the airway can happen with these fractures. Airway blockage can happen with excessive bleeding, swelling of the facial and neck tissues, or fracture and damage to surrounding structures. If there are burns also on the face, they can swell the tissue, blocking the airway. Fractures of the maxillary bone, nasal bones, and the mandible can lead to airway interference.

Bleeding can cause nausea and vomiting, which can obliterate the airway, especially if the patient has a loss of consciousness or impaired consciousness. Airway problems can occur early or late in the course of the injury so that the person needs to be monitored on a regular basis for a period of time after the injury.

Even though the facial fractures are not life-threatening, they can cause severe disfigurement and personal disability with physical and emotional effects that can be long-lasting. The eye can malfunction and can damage eyesight. The nose can be blocked if the septum is not repaired and the jaw can have problems opening and closing.

Broken bones can cause muscles and nerves to become entrapped. If this is the case, open surgery needs to be done as soon as possible following the injury. One common injury is the entrapment of the inferior or medial rectus muscles into the maxillary sinuses. Tear ducts and many different facial nerves can be entrapped and damaged by the fracture. The frontal bone fracture can cause damage to the frontal sinus, leading to a sinus infection and a mucocele, in which mucus builds up under the tissue.

Infection can occur with any open fracture of the face. Open fractures can open into sinuses, the nose, the orbit or the mouth. These need antibiotics to prevent infection.

General complications of nasal fractures also include:

  • An uneven face from a dislocated fracture
  • Excessive bleeding
  • Brain injury and leakage of CSF
  • Infection into the bone and tissues
  • Loss of vision
  • Double vision
  • Numbness of the face
  • Weakness of the face

Many of these complications can be avoided with prompt diagnosis and management of the more severe fractures as well as an exam that includes things like vision, movement, and sensation of the face.

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Editor’s Note: This page has been updated for accuracy and relevancy [cha 10.28.20]

Image by Anemone123 from Pixabay 

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