Emergency Department presentation by Dr Conor Dalby. Signs and symptoms to be aware of when assessing a patient following facial injury. Common types of fractures and their management. UK.

1. Facial
fractures
Conor Dalby
ACCS ST2

2. Contents
• History
• Clinical features
• Investigations in facial trauma
• Analysis of mid-face injury
• Orbital blow-out fracture
• Injuries to the mandible
• Le Fort
• Management

3. History
Once the ABCs have been stabilised and a basic history of the event and
PMH has been obtained, seek to answer the following questions:
1. Can you breathe out your nose on both sides?
2. Are you having any trouble speaking?
3. Any new visual disturbance?
4. Is your hearing normal?
5. Are you experiencing any numbness of your face?
6. Do your teeth come together as they normal would?
7. Any painful or loose teeth?

4. Clinical signs of facial fractures
sublingual
haematoma
Clinical Sign Underlying pathology
Flattened cheek Depressed zygomatic fracture
‘Dish face’ deformity, or elongated face Mid-face fractures
Saddle deformity of the nose Naso-ethmoidal fracture
Uneven pupils/diplopia Orbital floor fracture
CSF rhinorrhoea Base of skull fracture
Subconjunctival haemorrhage without posterior border Orbital wall fracture
Hypothesia:
• Numbness of the cheek, side of nose, and upper lip/teeth
• Numbness of the lower teeth and lip
Orbital floor fracture damaging the infraorbital nerve
Mandibular fracture damaging the inferior dental nerve
Subcutaneous emphysema Facial fracture into sinus
Dental malocclusion Maxillary or mandibular fracture
Sublingual haematoma or gum laceration Mandibular fractures

5. ‘Dish face’ deformity: mid-face fracturesFlattened cheek: depressed zygomatic fracture
Subconjunctival haemorrhage without posterior border:
Orbital wall fracture

6. Investigations for facial trauma
• ‘Facial views’ - Occipitomental
views are required in two
planes
• Mandibular AP view and
orthopantomogram (OPG) are
required for mandibular
injuries. OPG alone may miss
Symphysis menti fracture.
• Nasal X-rays are not indicated
• CT scanning may be required
to plan surgical intervention
but is best organised by the
maxillofacial team.

7. Analysis of a mid-face injury
Think of the zygoma as a mid face stool with 4 legs.
Concentrate on the stool’s legs. For each leg,
compared the injured side to the other (normal) side.
Look for any asymmetry or any difference between
the appearance of the matching legs. Check as
follows:
• Leg 1: zygomatic arch
• Leg 2: frontal process of the zygoma
• Leg 3: orbital floor/rim
• Leg 4: lateral wall of the maxillary antrum
• Look for fractures and look for:
• a fluid level in the maxillary antrum
• sinus air in the soft tissues or in the orbit
NOTE: If any one leg is fractured, always double
check that the other legs are intact (looking for ‘tripod’
fracture)

8. Isolated fracture of the
zygomatic arch. This is a
common injury (arrow)
Fracture of the inferior orbital
margin.
This may occur in isolation or
as part of a tripod fracture

9. ‘Tripod fracture’. In this combination injury the cheekbone
(zygoma) is detached from its four points of attachment to the
rest of the facial skeleton

10. Orbital blow-out fracture
Following blunt trauma, this injury may be
isolated, or accompany any other major or
minor facial injury. It results from a direct
compressive force to the globe. A squash
ball or a thrown egg are easy ways to do
this.
The blow causes a
sudden increase in the
intraorbital pressure
behind the eyeball.
resulting in fracture(s) of
the thin and delicate
plates of bone that form
the floor an medial wall of
the orbit.

11. Injuries to the mandible

12. Le Fort (mid-face fractures)
We can’t discuss facial fractures without mentioning le fort. He subjected cadaveric skulls to a variety of
blunt trauma and found 3 predominant patterns of fracture:
1.Le Fort I: fracture involving the tooth bearing portion of the maxilla. There may be an associated split in
the hard palate, a haematoma of the soft palate, and malocclusion.
2.Le Fort II: fracture involving the maxilla, nasal bones and medial aspect of the orbit. The maxilla may be
floating and cause potential airway obstruction.
3.Le Fort III: fracture involving the maxilla, zygoma, nasal bones, ethmoid and base of skull.
This is a useful classification for the maxillofacial surgeon when planning treatment. However, the Le
Fort patterns are not particularly helpful when carrying out step-by-step assessment of the plain
radiographs in the emergency department. As the Le Fort patterns involve the pterygoid plates, the only
reliable detail would be found on a CT scan, not a plain film.

13. Other facial injuries
Nasal fractures:
The most common facial fracture. The diagnosis is clinical and an Xray is not required.
A septal haematoma should always be assessed for, and if present, the patient should be
urgently referred for incision and drainage to avoid septal necrosis.
ENT follow-up at 5-7 days allows assessment of the nose once the swelling has subsided.
Temporomandibular joint dislocation:
TMJ dislocation is usually sustained by a direct blow to an open jaw or following
yawning/eating in patients with lax joint capsules/ligaments. Anterior dislocation is the most
common, however they can occur in any direction when occurs with fractures of the
mandible or base of skull.
Reduction of anterior dislocations can usually be achieved in the ED with the aid of
analgesia and sedation. Following reduction, the patient should have a soft diet, and be
advised not to open their mouth widely for 2 weeks.
Refer for outpatient maxillofacial follow-up.

14. Management of facial fractures
1. Resuscitate and establish a clear airway (ATLS)
2. Treat any epistaxis
3. Analgesia
4. Ensure appropriate tetanus prophylaxis
5. Avoid nose blowing (risk of surgical emphysema)
6. Prophylactic antibiotics may be indicated
7. Clean and cover facial lacerations, but do not close if associated with
fractures, because they can provide access for surgical reduction.
8. Head injury assessment and advice
9. Refer to maxillofacial surgery

15. References
• Stacey V. Revision notes for MCEM part B. Oxford University Press. 2012
• Raby N, Berman L, Morley S, de Lacey G. Accident and Emergency
Radiology a survival guide. Third edition. Saunders Elsevier. 2015.
• Sublingual haematoma:
http://www.studydroid.com/printerFriendlyViewPack.php?packId=419447
• Depressed zygomatic fracture:
http://www.slideshare.net/adorabledrakheel/maxillofacial-trauma-19339123
• Dish face deformity: http://medical-gal.tumblr.com/post/93113045135/emt-
monster-facial-fractures-le-fort-i
• http://www.rcemlearning.co.uk/modules/zygomatic-complex-and-nasal-
injury/clinical-assessment-and-risk-stratification/general-examination/