1 Facial fractures

Characteristics
Head and Face
● Often secondary to assault in adults and falls in children. Facial fractures
in children are suspicious of non-accidental injury (NAI).
● Emphasis on diagnosis rather than specific treatment in accident and
emergency (A&E). Functional loss and disability can be significant following
facial trauma.
● Consider cervical spine injury in all.
● Classified according to site – maxillary (sub-classified by Le Fort), malar,
infra-orbital, mandibular and nasal.

Clinical features
Maxillary
● Commonly associated with massive facial trauma and other organ
trauma. Presents with massive soft tissue swelling, mid-face mobility and
malocclusion. Cerebrospinal fluid (CSF) rhinorrhoea may occur secondary
to dural tears.
● Significant epistaxis can occur compromising both airway and circulation
and can require intervention.

Le Fort classification

Le Fort I involves tooth bearing

maxilla.
Le Fort III
Le Fort II involves maxilla, nasal
bones and medial
aspects of orbits.
Le Fort III involves maxilla, nasal
bones, vomer, ethmoids
and small bones of skull
base. Le Fort I Le Fort II
The face is separated
from the skull base.

Malar
● The zygoma may fracture in isolation or more commonly extend
through to the infra-orbital foramen with disruption of the zygomatico-
temporal and zygomatico-frontal sutures (tripod fracture).
● Look for cheek flattening, a palpable step, infra-orbital nerve damage and
diplopia.
● Intra-oral examination may reveal bony irregularity above and behind
6 the upper molars.
 1

Facial Fractures

Mid-face fracture – Le Fort II. Additional diastasis of the left zygomatico-

frontal suture (arrow).

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1 Facial fractures (continued)
Infra-orbital (blow out) fracture
Head and Face
● Enophthalmos and orbital emphysema may be evident. Diplopia may occur
secondary to ocular muscle (or orbital fat) entrapment.
● Globe injuries not uncommon, e.g. retinal detachment.

Mandibular
● Pain and tenderness and a palpable step may be evident. Malocclusion
common. May fracture distant to point of impact.
● Lip numbness suggests inferior dental nerve damage.

Radiological features
Maxillary
● Request facial views. Fractures can be difficult to see.
● CT scan often of benefit to delineate number and extent of fractures.
Helpful in planning surgery and subsequent follow-up.
● Fractures rarely occur in their pure form and are often asymmetrical.

Malar
● Facial views supplemented by submentovertex (SMV) views to visualise
the zygomatic arches.

Infra-orbital
● Facial views may show a ‘teardrop’, representing soft tissue, herniating into
the maxillary sinus. Complete opacification of the maxillary sinus occurs
secondary to haemorrhage and oedema and, if unilateral, should be
considered to be a secondary fracture until proven otherwise.
● Depression of the orbital floor may be visible.
● Air within the soft tissues may be seen with orbital emphysema.

Mandibular
● Confirm with a panoramic view (orthopantomogram, OPG) with
combined antero-posterior (AP) views.
● Condylar views may show a fracture or temporomandibular joint (TMJ)
dislocation. Coronal CT is of benefit in difficult to visualise condylar
fractures.

Management
General
● ABCs.
8 ● Make the diagnosis from clinical and radiological examination.
 1

Facial Fractures
(a)

(b)

Infra-orbital fracture. (a) ‘Teardrop’ sign. (b) Coronal CT demonstrating

the same.

9
1 Facial fractures (continued)
● Discuss with ear, nose, throat (ENT) surgeons.
Head and Face ● Antibiotics recommended for open fractures.

Special considerations
● Maxillary: Airway compromise is common and requires careful mainten-
ance. Epistaxis may require nasal packing/tampon. Operative interven-
tion for epistaxis is uncommon.
● Zygomatic: Depressed zygomatic fractures often require elevation.
● Infra-orbital: Spontaneous resolution of signs may occur and thus delayed
repair is often performed. In a patient with orbital emphysema with a
sudden decrease in visual acuity consider vascular compromise secondary
to raised orbital pressure.This is a surgical emergency.
● Mandibular: In most cases these require admission for occlusive or
mandibular wiring.

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 1

Facial Fractures
Left zygomatic arch fracture.

OPG: Fractures of right body and left ramus of mandible.

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