Emergency Medicine Clinics of North America
Volume 18 • Number 3 • August 2000
Copyright © 2000 W. B. Saunders Company
Edward Ellis III DDS
Department of Oral and Maxillofacial Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
Address reprint requests to
Edward Ellis III, DDS
University of Texas Southwestern Medical Center
5323 Harry Hines Boulevard CS3.104
Dallas, TX 75235-9109
One of the most demanding aspects of emergency practice is the management of the patient who has suffered facial trauma. Whenever a maxillofacial injury is sustained, the patient goes abruptly from a normal state to a state of tissue disruption. The abruptness of the injury can cause intense emotional distress even when only minor injuries are present. When an injury is located on or around the face, the perception by the patient or family and their reaction to the trauma can seem out of proportion to the actual degree of injury.
The goal of this article is to assist the emergency physician in the diagnosis and initial management of patients who have sustained traumatic facial injuries; there is no attempt to discuss surgical treatment of fractures. Clinicians participating in the initial assessment and management of these patients require a sound understanding of the various types of facial fractures and the principles involved in their initial evaluation and treatment, however. (Injuries to the facial soft tissues or the dental structures are covered elsewhere in this issue.) The authors' intent is to provide the basic fundamentals required to assess the patient with fractures of the facial skeleton confidently and to make an appropriate referral.
The outline of the article is perhaps not in keeping with the way patients present. The authors have divided the fractures into discrete locations that are common in clinical practice. When a patient with severe facial fractures presents to the emergency department (ED) however, he or she can present a constellation of findings that encompass signs and symptoms involving all regions of the face. The initial assessment must include components for all facial fractures.
The comprehensiveness of the primary evaluation and management frequently determines whether the trauma patient survives his or her injuries. Injuries to the head and neck frequently involve the airway and major vessels; therefore, the ABCs of resuscitation must be strictly adhered to in the primary phase of assessment and management of the patient with maxillofacial fractures. As is the case with any patient presenting with a traumatic injury, attention must first be directed to the overall evaluation of the patient. During the initial assessment, life-threatening injuries and systemic medical conditions must be appropriately evaluated. Patients with facial injuries should be suspected of having associated injuries, depending on the traumatic incident. The opportunities for coexisting trauma are higher in the patient involved in a motor vehicle collision (as opposed to the patient who has fallen or assaulted). There is also documented evidence of pediatric patients demonstrating a significantly higher percentage of associated injuries (73%), as compared with adults (58%). A greater number of cranial injuries have been documented in the pediatric population (55%) than in the adult group (39%). 
The initial assessment of the trauma patient is beyond the scope of this article; however, there are two peculiarities in patients with facial fractures that must be mentioned: airway and cervical spine injuries.
The airway is the first concern for the emergency physician. Patients who have sustained maxillofacial fractures can lose their airway because of lack of tongue support from mandibular fractures or obstruction of the airway from blood and debris. The mouth and pharynx should be cleansed of debris, and an oral or nasal airway inserted. For unstable patients, endotracheal intubation is advisable but must be performed cautiously because of the possibility of cervical spine injuries.
Until proved otherwise, one must assume that a patient who has sustained a facial fracture has an associated cervical spine fracture. Studies have revealed around 1% to 4% of patients with facial fractures also have injuries of the cervical spine.    
Once the patient has been stabilized and cleared for cervical spinal cord injuries, the physician can begin to evaluate the maxillofacial region. If possible, the history of events surrounding the injury should be obtained because it can provide clues to the type of injuries the patient could have. For example, a sharp, penetrating injury is more likely to injure nerves and major vessels than is blunt trauma, which is more likely to result in fractures of the facial skeleton.
A few questions to responsive patients can give valuable clues to the presence of skeletal fractures:
The clinical evaluation of the maxillofacial region must be organized and sequential and should be performed prior to ordering radiographs and other images. The head and neck examination must be methodical, or significant injuries can be missed. The maxillofacial examination must include the following components:
One approach organizes the examination from "inside out and bottom up." Following this recommendation, the oral cavity is inspected first for lacerations or penetrating injuries. The tongue is frequently lacerated and can produce profuse bleeding. Soft tissue injuries should be explored for tooth fragments and other foreign bodies. Areas of soft tissue swelling and ecchymosis are noted because they can indicate underlying skeletal fractures. Lacerations of the attached gingiva around the teeth or palate also can indicate an underlying fracture.
The dentition is evaluated to determine if empty tooth sockets are present, indicating tooth avulsion. All such teeth should be accounted for; they can be displaced into soft tissues, can have entered the bronchi or esophagus, or can have been left at the scene of the injury. Any patient with partial airway obstruction or bronchoconstriction should have chest radiographs obtained to rule out foreign bodies within the lungs. Abdominal radiographs also should be ordered when teeth are missing during the clinical examination. The dentition is also evaluated for mobility, because mobile teeth can indicate underlying skeletal fractures. The presence of irregularities of the dentition within a dental arch usually indicates a skeletal fracture, especially if there is mobility across the area.
An examination of the maxillofacial skeleton involves inspection and palpation. Injuries in the maxillofacial area can be associated with massive edema, which makes evaluation of the underlying skeleton difficult; however, bony contours should be palpated for irregularities and tenderness (discussed in their specific regions). One should always inspect carefully any fluid exiting the nose in case it could be cerebrospinal fluid (CSF). The presence of CSF rhinorrhea indicates disruption of the anterior cranial base, most commonly at the cribriform plate of the ethmoid bone associated with naso-orbitoethmoid fractures, or from disruption of the posterior wall of the frontal sinus. Areas of "numbness" on the face should make one suspect disruption of the sensory branch of the trigeminal nerve from skeletal fractures.
After the patient is stabilized and examined, appropriate images should be obtained. Patients with suspected cranial trauma should have appropriate CT scans of the skull and brain. If there are obvious or suspected facial fractures and the patient is relatively stable, consideration should be given to performing axial cuts from the bottom of the mandible to the top of the skull. The new generation of spiral CT scanners can perform such an examination in a few minutes. Having CT scans of the entire face aids in diagnosis of facial fractures and can save the patient the inconvenience and expense of returning to the scanner when the maxillofacial surgeon requests CT scans for treatment planning.
Although a systematic approach to the examination of the patient's facial skeleton and surrounding tissues is mandatory, for educational purposes the authors have divided the face into skeletal regions and the examination and initial treatment of that region is discussed under each division.
Fractures of the mandible can be located in the symphysis, body, angle, ramus, and condyle or subcondyle regions (Fig. 1). The location of the fracture has some relationship to the cause of the injury. Motor vehicle collisions tend to cause fractures of the condylar and symphysis regions because the force usually is directed against the chin (symphysis). Commonly, high-impact forces directed against the chin result in a combination of symphysis and one or both condylar regions being fractured. High-velocity impact also tends to create comminution and multiple region fractures. Injuries sustained in altercations are more commonly located in the mandibular angle region, especially on the left side, where the (more common) right-handed person has struck a blow.
Injuries to the mandible can occur by both indirect and direct forces. As previously mentioned, a condyle fracture can be the result of a blow to the symphysis, fracturing the symphysis (direct) and pushing the mandible posteriorly, thus resulting in an indirect condylar injury. At least one half of mandibular fractures have two, not one, fractures. In the case of altercations, the combination of the mandibular angle on the side of impact (direct), and the contralateral mandibular symphysis or body (indirect) fractures commonly occur.
History and Clinical Examination
Fractures of the mandible reveal themselves differently, depending on the location and severity of the injury. For example, fractures in the body of the mandible present differently on clinical examination than do those of the condyle. A fracture can be obvious if it has a large degree of displacement, which has caused lacerations in the mucosa or skin; however, such injuries are uncommon. Of a conscious patient, ask the following questions:
These three questions should be able to direct the clinician to most fractures of the mandible. A thorough clinical examination should then be performed that includes both inspection and palpation. First, examine the patient's face for swelling and symmetry. An asymmetry can often be minor but can be exaggerated when large hematomas, displacement of fractures, or amounts of edema have occurred. Occasionally, a patient has a widened appearance to the face, partially obstructing the ears while one looks at the patient from the front (Fig. 2 A). This can indicate the combination of bilateral condylar fractures combined with a fracture of the symphysis, allowing the mandible to open like a book, with lateral displacement of the mandibular rami (Fig. 2 B). If the patient were injured in a high-velocity impact, this would heighten suspicion for such a combination of fractures. One should then gently palpate the borders of the mandible through the skin to determine if any irregularities or areas of tenderness are found (Fig. 3 A). Any irregularity that is sharp and well defined should be considered a fracture, because the mandible has smooth contours. Areas of tenderness are not pathognomonic for fractures, but should heighten one's suspicion, especially if they are in areas of swelling. The preauricular area should be palpated (Fig. 3 B). If tender, the temporomandibular joint has, as a minimum, effusion/hemarthrosis, and possibly a fracture. The external auditory meatus must be inspected for bleeding. Occasionally, the mandibular condyle can be pushed posteriorly enough to create a tear in the external auditory meatus. One should also place one finger in the ear canal, pressing anteriorly within it, to determine if there is tenderness within the temporomandibular joint. This is a more reliable method for determining intracapsular tenderness than preauricular palpation. Before performing an intraoral examination, one should quickly assess the sensitivity in the distribution of the mental nerve using a cotton swab with the eyes closed, comparing one side to the other; if both feel "numb," use the upper lip as a control.
After a thorough external examination, one should perform an intraoral examination. First, have the patient open the mouth as wide as he or she can to allow visual inspection of the mandibular dentition and surrounding soft tissues. If there is an obvious irregularity or separation between the lower teeth, a fracture is present (Fig. 4). Fractures of the mandible usually are associated with a tearing of the gingival tissue, and hematomas on both the buccal (outer) and lingual (inner) sides of the jaw. Frequently, hematomas on the lingual side extend into the floor of the mouth, causing discoloration and rapid swelling of the loose lingual soft tissues, elevating the floor of the mouth. Be sure the patient's tongue is mobile, and check to see if he or she can protrude it. If they have good control of tongue movement, they will probably be able to maintain the airway, even if further swelling occurs. Next, palpate along the buccal and lingual surfaces of the mandible to determine if any irregularities or areas of tenderness are observed. Sharp irregularities usually indicate a fracture. Areas of tenderness are not pathognomonic for fracture, but if a fracture is present, pain is associated with it. Often, there may be loose or avulsed teeth along the line of fractures. Edentulous patients can present with broken dentures. One should check for fractured teeth or denture fragments that can be embedded in the soft tissues. Next, manipulate the tooth-bearing regions of the mandible, using two gloved hands (Fig. 5). Place one finger over the occlusal surface and the thumb under the mandible outside of the mouth. Using two hands in this manner, one should attempt to find areas of mobility along the accessible regions of the mandible. Occasionally, fractures are nondisplaced and nonmobile, and the only clue to their presence is the ecchymosis they cause in the soft tissues or numbness of the lower lip and chin. The patient should then be asked to bite the teeth together to allow an assessment of the dental occlusion. Depending on the amount of swelling or pain the patient has, he or she could find it difficult to occlude their teeth. If it appears they are able to occlude and the teeth do not contact symmetrically, one must decide if the malocclusion is due to a fracture or is a preexisting malocclusion (Fig. 6). What appears to be a large malocclusion could be normal for that patient. If the patient has no other signs or symptoms for fracture, with the exception of a malocclusion, one must consider that there could be a fracture behind the tooth-bearing region, most commonly in the condylar/subcondylar region. This can cause a shifting of the bite toward the side of fracture, and when the patient is asked to open his or her mouth, they will deviate to that side (Fig. 7).
CT is not routinely employed for assessment of most mandibular fractures. Plain films are still the most common images obtained. Many hospitals have instituted a series of films they prefer to take for the assessment of mandibular fractures. A typical mandibular series includes right and left lateral oblique, posteroanterior (PA) and Towne's (for assessment of subcondylar fractures) views. The most productive screening film is the panoramic radiograph, although this is not widely available in smaller hospitals. The combination of panoramic and PA mandible radiographs has been shown to provide extremely good reliability for diagnosis of mandibular fractures (Fig. 8).
The tongue is supported by the mandible, and some fractures of the mandible can cause loss of this supporting role. Bilateral mandibular fractures, especially bilateral condylar plus symphysis fractures, can cause loss of tongue support, allowing posterior displacement of the tongue (Fig. 9). Mandibular fractures caused by gunshot wounds with comminution can also create a situation in which the mandible cannot support the tongue. The airway must be maintained in such cases, using airway aids.
Fractures of the mandible that are in a tooth-bearing region are compound fractures, even if nondisplaced. Because bacteria from the mouth and saliva bathe the surfaces of the fracture until the soft tissues have healed adequately enough to seal the wound, prophylactic antibiotics should be started as soon as possible. The drug of choice for oral aerobes and anaerobes is still penicillin G for intravenous and penicillin VK for oral administration. Clindamycin can be used for patients allergic to penicillin.
Patients with mandibular fractures can be made more comfortable until definitive treatment is performed by temporarily immobilizing the fracture fragments. This is most simply performed in tooth-bearing segments of the mandible by placing a 24 gauge wire around the necks of two teeth on each side of the fracture, and tightening it to close and immobilize the fracture. One should not place such a wire only on the teeth adjacent to the fracture, because they are frequently loose.
Maxillary fractures are less common than those of the mandible, and when they occur they are usually associated with other midfacial fractures. Almost all maxillary fractures involve the dental occlusion, although a few are fractures of the anterior wall of the maxilla above the level of the teeth. These do not usually warrant treatment. Classically, maxillary fractures are broken down into the Le Fort classification (Fig. 10).
The Le Fort I fracture is a horizontal fracture above the roots of the teeth, extending from the piriform aperture of the nose to the pterygomaxillary fissure, separating the maxillary tuberosity from the pterygoid plates. The mobile maxillary fragment is like a loose denture, containing the teeth and palate. It can be a single fragment or in multiple segments. This fracture is commonly the result of a horizontal force applied to the anterior maxilla.
In a Le Fort II fracture, the maxilla and its approximating nasal complex together are separated from the orbital and zygomatic structures. Instead of the fracture along the anterior maxilla extending from the pterygomaxillary fissure into the piriform aperture, as it does in the Le Fort I fracture, it courses upward through the infraorbital rim, over the medial orbit and nasal bones. Because of this pattern, it is also called a pyramidal fracture.
A Le Fort III fracture has also been termed craniofacial separation, because the maxilla, naso-orbitoethmoid complex, and zygomas are separated from the cranial base.
The Le Fort classification is therefore more a midfacial fracture classification than one for maxillary fractures because of the involvement of other facial bones. Unfortunately, the classic descriptions (above) of Le Fort fractures are almost never seen in practice. The midfacial skeleton is made of thin bony septae separating large, air-filled spaced (i.e., the sinuses, and nasal cavity) and the soft tissues of the orbit. Rarely do fractures in the midface follow the bony sutures, and rarely are they linear fractures (Fig. 11). The fractures follow paths of least resistance, regardless of which bone they course through, and they are almost always comminuted and multiple. Therefore, instead of a single-piece Le Fort II or III fracture, most often the nasal or zygomas are disconnected to the main maxillary tooth-bearing fragment.
History and Clinical Examination
Maxillary fractures almost always are associated with large amounts of facial edema, masking facial deformities, including those that result from posterior displacement of the maxilla (see Fig. 11). Because of the significant blood supply in the maxilla, severe bleeding can occur and often presents through the nose or down the back of the throat. Even in minor maxillary injuries, it is common to find epistaxis secondary to tearing of the sinus mucosa. Injuries to the cribriform plate are not uncommon for the more severe injuries, resulting in cerebrospinal fluid rhinorrhea. Approximately 50% to 70% of pediatric patients with midface trauma also show injuries to the cranial base, cervical spine, chest, and abdomen.
Just as with the mandible, fractures of the maxilla usually result in symptoms that can be readily revealed by a conscious patient. Patients therefore should be asked the following questions:
These three questions are less helpful for diagnosing maxillary fractures than they are for fractures in the mandible but then can help to direct the clinician in the remainder of the examination. A thorough clinical examination should then be performed, which includes both inspection and palpation. First, examine the patient's face for swelling and symmetry. An asymmetry is often minor but can be exaggerated when large hematomas, displacement of fractures, or edema have occurred. Palpate for bony steps and point tenderness along the orbital rims and across the bridge of the nose. Because of the different levels possible, there can be multiple bony fractures noted.
Grasp the anterior maxillary teeth with thumb and finger and apply force to determine if there is mobility. Impacted maxillary fractures may not be mobile even to firm manipulation. If mobility is detected, determine the level of the fractures by palpating with the other hand on the face over the bridge of the nose, the infraorbital rims, and the zygoma (Fig. 12). If none of those structures moves when the maxilla is moved, a Le Fort I level fracture should be suspected. If the nasal bridge moves with the maxilla, a Le Fort II level fracture should be suspected. If the nasal bridge, infraorbital rims, and zygomas move in concert with the maxilla, a Le Fort III level fracture can be suspected. Inspect the dental arch and palate for ecchymosis, mucosal tearing, and separation or avulsion of teeth. One should be sure to record the results of an infraorbital neurosensory examination.
The midfacial skeleton is much more difficult to assess using plain films than is the mandible. The presence of thin bones, fluid-filled spaces (e.g., congested sinuses), and soft tissues (e.g., orbital contents) make accurate assessment difficult with images that do not offer a high degree of contrast. If the clinical examination is equivocal and one is unsure of the presence of a fracture, one should obtain a plain Water's image. If there are any positive findings, such as clouding of the sinuses, one should obtain axial and coronal (cervical spine permitting) CT scans from the teeth through the top of the frontal sinus. If orbital involvement is suspected, 2-mm to 3-mm cuts should be obtained. If the cervical spine is unstable, one can obtain axial scans with reconstructed coronal images; however, these are of much poorer quality than are direct coronal scans. Because of the ability of CT to distinguish tissues of varying contrast, one can assess the location and displacement of midfacial fractures much better with CTs than with a thorough clinical examination.
It is extremely rare for a midfacial fracture to cause airway obstruction; however, the significant blood supply to the midface can result in life-threatening hemorrhage. Patients may not present with an impressive amount of bleeding from the mouth or nose because the blood can enter the oropharynx through the nasopharynx. In such instances, patients can swallow great volumes of blood before the emetic action of blood induces a violent and impressive emesis, frightening to the patient and ED personnel. With severe bleeding, nasal packing can be lifesaving; however, if the maxilla is mobile, packing the nasal cavity with gauze serves only to displace the maxilla inferiorly, and there may be no skeletal support against which to pack. In a hemorrhagic emergency, a Foley catheter can be inserted into the nasopharynx through both anterior nares, and the balloons inflated with air (not water; Fig. 13). Once the balloons are inflated, the catheters can be pulled anteriorly to close off the posterior choanae and can be tied to one another as they exit the anterior nares. The remainder of the nasal chamber can then be packed with gauze. Posterior nasal packs using a roll of gauze wadding can be used similarly.
Patients with CSF rhinorrhea should have a neurosurgical consultation. Placing the patient on prophylactic antibiotics can vary according to the particular neurosurgeon consulted. Prophylactic antibiotics for the maxillary fracture are usually warranted, however, because such fractures are considered compound when they extend through the tooth-bearing region or through the mucosa of the nasal and sinus cavities. The antibiotic of choice in such fractures is either a penicillin that is effective against Haemophilus influenza as well as oral contaminants (e.g., ampicillin, amoxicillin) or a cephalosporin. For patients allergic to penicillin, clindamycin is useful.
For patients with maxillary and other midfacial fractures, one should use caution when passing tubes through the nose (i.e., nasogastric or endotracheal) because the anterior cranial base can be violated. Theoretically, a fracture in the cranial base could allow passage of the tubes posteriorly into the cranium, although this has been documented in only a few cases.
The zygoma is a prominent bone in the facial skeleton, making it prone to fracture. It articulates extensively with the maxilla along the anterior maxilla, infraorbital rim, and orbital floor; the frontal bone at the frontozygomatic suture of the lateral orbit; the temporal bone at the zygomatic arch; and the sphenoid along the lateral wall of the orbit (Fig. 14). The zygoma forms a large part of the lateral and inferior walls of the orbit, as well as a portion of the roof and lateral wall of the maxillary sinus.
Because the zygoma is thick, and fractures of this region occur in areas where support is weakest, it is rare to have an isolated fracture of the zygoma in which the fracture lines are completely within this bone or through only the sutures surrounding it. Most commonly, the fracture lines extend through adjacent bones, which are thinner. Zygomatic fractures are orbital fractures, because the internal orbit can sustain disruption during displacement of the zygomatic body; this is why fractures of the lateral midface are sometimes called as zygomatico-orbital fractures. Others call them malar fractures, but most commonly, perhaps, is the term zygomaticomaxillary complex (ZMC) fracture, indicating that the injury involves the zygoma and adjacent bones. In all such fractures, at least one fracture through the zygomatic arch occurs. ZMC fractures must be distinguished from those of the zygomatic arch only, whereby the zygomatic body is intact and only the arch extending from the body of the zygoma to the temporal bone is disrupted.
The zygoma has numerous muscles attached to it, including the masseter. The combination of the direction of the disrupting force (usually posterior and medial) and the pull of the masseter muscle causes inferior and posterior displacement of the usual ZMC fracture. Because of its involvement with the internal orbit, complications of the orbit are not uncommon.
History and Clinical Examination
There are two questions that can be asked of a conscious patient that can be very useful in determining the presence or absence of a ZMC fracture:
ZMC fractures almost always are associated with large amounts of facial edema, masking facial deformities, including those that result in posterior displacement of the ZMC. One could therefore not realize the true extent of the injury. The eyelids can swell to the point where they cannot be easily opened. If facial edema is minimal, one should inspect for symmetry, comparing one side with the other (Fig. 15). This should be performed by standing directly in front of the patient, as well as behind and above the recumbent patient (i.e., "bird's eye" view). Any posterior displacement of the zygoma is best observed from the bird's eye view. Periorbital or subjunctival ecchymosis should be noted, because this can indicate that there has been disruption of the periosteum of the orbit. Vertical dystopia can be present because the lateral attachments of the orbital soft tissues remain attached to the inferiorly displacement ZMC, pulling down the ocular globe and the lateral canthus. As with any orbital fracture, patients may experience binocular diplopia.
The orbital rims should be palpated to detect areas of irregularities and tenderness (Fig. 16 A). Most fractures of the orbital rim occur through the frontozygomatic suture, located at the junction of the superior one-third and inferior two-thirds of the lateral orbital rim, and through the medial one-third of the infraorbital rim. Palpation is most revealing when done symmetrically and bilaterally. One can slide a gloved finger into the maxillary vestibule and palpate the contour of the zygomaticomaxillary buttress, which is almost always disrupted in ZMC fractures (Fig. 16 B). Submucosal ecchymosis often accompanies the fracture in this location.
Because tearing of the sinus mucosa occurs, the maxillary sinuses usually fill with blood and secretions, which can result in epistaxis. In such cases, however, the epistaxis is not brisk, frequently postural, and requires no active control.
The only findings in a patient with an isolated zygomatic arch fracture are trismus and a shallow depression in the temporal region. The depression might not reveal itself for a week or more, until after the edema has dissipated.
A single Water's image can be used as a scout film to determine the presence or absence of abnormalities, such as clouding of the maxillary sinus or disruption in osseous contours. If a fracture is suspected, axial and coronal computed tomograms (2-mm to 3-mm cuts) of the entire maxilla and orbit provide a complete assessment of the injury (Fig. 17).
For isolated zygomatic arch fractures, the submentovertex (SMV) plain image, when properly exposed, is sufficient (Fig. 18).
The bony orbit is made of seven bones of varying thickness. Superiorly, the supraorbital rim and orbital roof is formed by the thick frontal bone. Inferiorly, the floor and infraorbital rim is formed by the zygoma and maxilla. The lateral wall is thick and is made of the greater wing of the sphenoid and the zygoma. Medially, the orbit is formed primarily by the lamina papyracea of the ethmoid. The bony orbit has very strong buttresses anteriorly along the infraorbital rim and posteriorly at the apex. In between is a large area of anatomic weakness, especially in those areas where the bones are very thin. The floor of the orbit is also weakened by the groove for the infraorbital nerve, which courses through it.
Fractures of the orbit can be either pure, whereby the internal orbit is disrupted without a disruption of the orbital rims, or impure, whereby a fracture of the orbital rim is also involved with the internal orbital fracture. A ZMC fracture represents an impure orbital fracture because the disruption is both internally and along the rim. The term blow-out fracture refers to a pure internal orbital fracture, created by a sudden increase in intraorbital pressure by compression of the orbital contents against a volumetrically constrained orbital socket. The force creates fractures of the internal orbit in areas where the bone is thinnest (i.e., along the floor and medial wall), which then displace into the air spaces of the ethmoid and maxillary sinuses. Intraorbital soft tissue contents also herniate into the maxillary and ethmoid sinuses.
History and Clinical Examination
After lifesaving measures, maintenance of vision is the next most important goal in the care of the maxillofacial trauma patient. The first priority following ascertaining the neurologic status of a patient with suspected orbital fracture is the visual status of the involved eye(s). A thorough ocular and funduscopic examination should be performed with complete documentation of the findings. Ocular injuries, such as vitreous hemorrhage, hyphema, globe laceration, severance of the optic nerve, and corneal abrasions, were found in 4% of patients with midfacial trauma by Turvey  and in 5% of zygomatico-orbital fractures by Livingston and colleagues.  Ophthalmologic consultation was deemed necessary in approximately 5% of 2,067 cases of zygomatico-orbital injuries reported by Ellis and colleagues.  Ioannides et al found significant ocular/adnexal injuries in 26% of orbital fractures.  Al-Qurainy et al prospectively performed ophthalmologic examinations in 363 patients who had sustained midfacial fractures.  Minor or transient eye injuries, such as corneal abrasion, chemosis, mild impairment of accommodation and visual acuity, and orbital emphysema, were found in 63% of patients. Moderate injuries, such as enophthalmos, conjunctival abrasion, traumatic pupillary changes, iridodialysis, lens damage, macular edema, moderate-to-severe impairment of accommodation and visual acuity, were noted in 16% of patients. Severe ophthalmic disorders, such as gross proptosis, retrobulbar hemorrhage, corneal laceration, hyphema, angle recession, severe reduction/loss of vision, visual field loss, choroidal tear involving the macula, and optic nerve injuries, were found in 12% of patients. One third of all patients with comminuted ZMC fractures suffered a severe ocular disorder. Therefore, if there are any significant or questionable findings in patients with midfacial fractures, ophthalmologic consultation should be obtained.
Diplopia is the term for the symptom of blurred vision. There are two varieties of diplopia that are important to distinguish. Monocular diplopia, or blurring of the vision through one eye with the other closed, requires the immediate attention of an ophthalmologist because it usually indicates a detached lens, hyphema, or other traumatic injury to the globe. Binocular diplopia, where the blurring of vision occurs only when looking through both eyes simultaneously, is common and occurs in approximately 10% to 40% of orbital injuries.  Al-Qurainy et al found that the severity of diplopia was associated with the severity of midfacial injuries.  Binocular diplopia that develops following trauma can be the result of soft tissue (i.e., muscle or periorbital) entrapment, neuromuscular injury, intraorbital or intramuscular hematoma/edema, or change in orbital shape, with displacement of the globe causing a muscle imbalance. Enophthalmos and globe ptosis associated with marked displacement of the globe can also cause diplopia.
A useful point in differentiating the cause of diplopia is the finding that general edema of the orbit usually causes diplopia in the extremes of upward and downward gaze. Almost complete lack of eye movement in one direction is present with mechanical interference or neuromuscular injury, most commonly muscle entrapment (Fig. 19). The diagnosis of diplopia can be difficult in the early stages, when severe edema of the orbit and eyelids is present. Diplopia of edema or hemorrhage origin should resolve in a few days, whereas entrapment of orbital tissues does not.
One can determine whether entrapment of orbital contents by the fracture through the orbital floor is present by a forced duction test; for this, small forceps are used to grasp the tendon of the inferior rectus through the conjunctiva of the inferior fornix, and the globe is manipulated through its entire range of motion (Fig. 20). Inability to rotate the globe superiorly signifies entrapment of the muscles in the orbital floor. This test should differentiate between entrapment of orbital contents and paralysis caused neuromuscular injury or edema. It should be performed routinely in those patients who cannot rotate the globe into an upward gaze.
The orbital rims should be palpated to detect irregularities (Fig. 16 A). Be careful, however, not to be misled by the foramina or notches of the supraorbital and infraorbital nerves; which can feel irregular enough to consider them being fractures. Bilateral symmetric palpation can help to resolve this by comparison to the opposite side. One should ask the conscious patient the following question: "Is your lower eyelid and/or upper lip numb?" The infraorbital nerve courses along a canal in the floor of the orbit and usually is disrupted during a fracture of the orbital floor. This causes numbness to the distribution of the infraorbital nerve (i.e., lower eyelid, side of nose, or upper lip). Any patient with this symptom should have CTs obtained of the orbit(s).
If an orbital fracture is suspect, fine-cut (2-mm to 3-mm) axial and coronal (cervical spine permitting) CTs should be ordered (Fig. 21); no other method of examination is an adequate substitute for imaging the internal orbit. The importance of properly diagnosing internal orbital fractures is highlighted by the problem that often develops when they are not diagnosed and treated. Post-traumatic enophthalmos develops weeks to months after orbital fractures in which there has been a significant increase in orbital bony volume. Orbital volume cannot be assessed by a clinical examination, especially in the acute setting, because soft tissue edema always prevents recognition of enophthalmos. Once the swelling has dissipated, enophthalmos becomes more obvious and frequently is associated with ptosis of the globe. The clinical manifestations of enophthalmos are accentuation of the upper lid sulcus and narrowing of the palpebral fissure, causing pseudoptosis of the upper lid. The anterior projection of the globe, as viewed from above, is reduced on the side of injury. The major problem with not recognizing an increase in orbital volume and treating it early is that secondary correction of the condition is difficult and associated with less than optimal results. Early surgery to reconstruct the orbital volume has been shown to prevent the occurrence of enophthalmos. Therefore, the emergency physician should have a high degree of suspicion that fractures of the internal orbit have occurred in patients who present with periorbital injuries. The only method by which they can be diagnosed is by CT.
Any abnormal or equivocal findings on the funduscopic or ocular examination should prompt one to consult an ophthalmologist. If the globe is proptotic and tense, a retrobulbar hematoma should be suspect (Fig. 22 A). A quick and simple maneuver that can help relieve some of the intraocular pressure is to perform a lateral canthotomy. A drop of local anesthetic should be injected in the region of the lateral canthal tendon, and a small sharp scissors can be inserted between the fusion of the upper and lower eyelids pointed toward the lateral orbital rim. The upper and lower divisions of the lateral canthal tendon can then be snipped to the level of the bone (Fig. 22 B).
The use of prophylactic antibiotics for orbital fractures is controversial, and there is no consensus on whether they are indicated. Infections after orbital fractures are rare.
Fractures of the nose are common and often go undiagnosed, with many patients never even presenting for evaluation. Patients undergo some traumatic event, resulting in a bloody nose, and never seek attention once the nose stops bleeding. Isolated fractures of the nasal bones alone are very rare. The entire nasal complex usually is involved, and there is often damage to the underlying bones and cartilages. Frequently, there is extension to the frontal and ethmoid bones. Fracture of the nasal septum usually is associated with nasal fractures and may create the only functional problem (nasal airway obstruction).
An important difference between the adult and pediatric nasal fracture is that the nasal bones are not fused in children until adolescence, so that they fracture each individual bone. Further, injuries to the nose and nasal septum can result in growth dysplasias.
Most injuries to the nose occur from the side, which dislocates both nasal bones and the nasal septum to the opposite side. Patients who do not seek treatment or have unsatisfactory treatment often complain of nasal airway obstruction secondary to the deviated nasal septum.
The term naso-orbito-ethomidal (NOE) fracture refers to a more severe injury, in which not only the nasal bones are involved but also the nasal processes of the frontal bone and the frontal process of the maxilla. The bones involved in NOE injuries are at the "anatomic crossroads" among the cranial, orbital, and nasal cavities. In such fractures, the orbital rim and nasal pyramid frequently become displaced posteriorly. The middle segment of the orbital wall and nasal septum, being thin, crumbles, absorbing the shock and sparing the posterior segment from more severe displacement.
In addition to the disorganization of the skeletal framework produced by the backward displacement of the bony structures between the orbits (i.e., interorbital space), fractures involving the cribriform plate and anterior cranial fossa can result in cerebrospinal rhinorrhea and brain damage. Fractures of the medial orbital rim cause displacement of the medial canthal tendon, lacrimal apparatus, and suspensory ligaments of the eyelids and globe (Fig. 23). Positional disruption of the medial canthal tendon results in telecanthus, or an increase in the distance between the medial commissures of the eyelids.
A direct blow to the midface can result in fractures of the bony NOE complex and injury to the adjacent soft tissues. A common source of such injuries is rapid deceleration to an unrestrained subject when the bridge of the nose strikes the steering wheel or dashboard of a car. These injuries can be confined to the NOE complex, but frequently they are associated with other facial fractures and are often complicated by multisystem trauma.
As with other facial fractures, periorbital ecchymosis and massive swelling are often present (Fig. 24). The first priority is the status of the globes, and so a thorough ocular examination therefore must be performed. Observe the nose for symmetry and midline positioning, and note the intercanthal distance (Fig. 25). This can be difficult to assess when edema is marked. The average distance is approximately 30 mm to 34 mm. A flattened and broadened nasal bridge is sometimes seen in NOE fractures, and ptosis of the upper eyelid can occur. Epiphora can be secondary to damage of the lacrimal duct. Palpate the nasal complex for mobility and for any bony steps (Fig. 26); crepitus can be present. Most patients have varying amounts of epistaxis from nasal injuries; however, any fluid running out of the nose should be inspected for the possibility of CSF (Fig. 27). A nasal speculum should be used to inspect internally for position of the septum and the presence of mucosal tears or hematomas.
Radiographs are not always necessary for nasal fractures, except to confirm the clinical impression. If an NOE fracture is suspected, however, fine-cut axial and coronal CT scans are the images of choice (Fig. 23).
Simple nasal fractures frequently require no immediate intervention unless epistaxis is problematic. Bleeding from the nose that continues beyond several minutes after the injury could require the insertion of nasal packing or commercially available hemostatic balloons or other devices. The use of a nasal speculum to dilate the external nares is helpful when one packs the nose. Gauze that is moistened with saline or antibiotic ointment is easier to pack, with less mucosal damage than dry gauze strips. One should pack methodically, beginning high in the nasal chamber, just under the nasal bones, and continuing inferiorly. This can be difficult to perform in an awake patient because of the pain it engenders.
One should exercise all the concern for patients with NOE fractures that one demonstrates for patients with orbital fractures (discussed previously) with respect to the status of the ocular globes. In addition, however, is the concern that the cribriform plate of the ethmoid bone has been disrupted, producing CSF rhinorrhea. CSF rhinorrhea is common after NOE fractures.  The bone of the anterior skull base is thin, with densely adherent dura. The T-shaped mass of the crista galli and cribriform plate is strong and moves as a unit with a significant blow to the nasal bridge, creating fractures in the medial fovea ethmoidalis.  The presence of CSF rhinorrhea is not diagnostic for a NOE injury, however, because this can accompany frontal sinus, orbital roof, and Le Fort fractures. Neither is its absence evidence against a NOE fracture, because many patients do not experience CSF rhinorrhea.
For CSF rhinorrhea to occur, trauma to the anterior cranial fossa must cause disruption of the arachnoid, a tear in the dura, and a fracture of bone (as well as a tear through the periosteum and mucosa). The incidence of meningitis varies widely from one study to another but is quite low (from 4%-10%) in those who have CSF fistula.   Whether one should administer antibiotics for CSF rhinorrhea, and if so which antibiotics, is usually a decision made by the neurosurgeon and usually is based on personal preference rather than scientific data.
Frontal sinus injuries most often result from blunt trauma, such as when an unrestrained person's head strikes the dashboard or steering wheel of a car. Compared with other facial fractures, frontal sinus fractures are uncommon. Because of their anatomic proximity to the nose, orbits, and brain, however, they can result in significant morbidity.
The frontal sinus can range in size from nonexistent to filling the entire forehead region of the frontal bone. The outer table of bone is much thicker than the inner table. Just deep to the inner table of bone is the meninges, the outer layer of which (dura) forms the periosteum of the cranial cavity. The floor of the frontal sinus consists of the orbital part of the frontal bone, which, in extensively pneumatized sinuses, can overlie the optic nerve. Anteriorly, the floor of the frontal sinus overlies the ethmoid sinuses and nasal cavity. The frontal sinus drains into the middle meatus of the nose by the nasofrontal ducts or ostia. The patency of the drainage system is extremely important to ascertain when making decisions about whether to treat a fractured frontal sinus and which treatment is warranted.
Because injuries to the frontal sinus/bone indicate that a great amount of energy was absorbed by the skull, one should always suspect injuries of the central nervous system. Therefore, a thorough cranial nerve examination and determination of level of consciousness is mandatory before further diagnostic measures for the facial fractures are undertaken.
Some frontal sinus injuries are obvious, but most are not. One should therefore be highly suspicious of patients who have been struck in the forehead region, because frequently, lacerations accompany fractures of the frontal sinus. These types of fractures should be explored carefully to determine whether an underlying skeletal fracture is present. If a fracture cannot be palpated, however, one should not assume that none exists. Patients can have displaced posterior table fractures without palpable anterior table fractures. Most patients have soft tissue swelling over the forehead region, which has a characteristic "doughy" feel (Fig. 28 A). Crepitus is noted when palpating the frontal sinus region if there are multiple fragments of bone that are mobile.
One should examine the nasal chamber and any fluid that is within for the presence of CSF. Frontal sinus fractures are often associated with other midfacial fractures, such as naso-orbito-ethmoid or nasal. These patients therefore should also be examined as if they had orbital fractures (see earlier discussion).
Any suspicion of frontal sinus fracture(s) should prompt the acquisition of axial CTs. CTs allow an accurate assessment of the anterior and posterior tables, the presence of fluid within the sinuses, the presence of air within the cranial cavity (i.e., pneumocephalus), the presence of brain swelling or associated injuries, and associated facial fractures (Fig. 28 B).
Like other facial fractures, frontal sinus fractures usually are not medical emergencies, although the presence of CSF rhinorrhea can be a life-threatening condition if meningitis develops. A neurosurgical consultation is generally warranted if CSF rhinorrhea or posterior table fractures are present. Whether to begin administration of prophylactic antibiotics (and if so, which) is up to the discretion of the neurosurgeon.
A thorough ophthalmologic examination must also be performed on all patients with frontal sinus fractures. One study has documented 89% of patients with frontal sinus fractures had associated eye injuries.  Whether a formal ophthalmologic consultation should be obtained depends on the initial findings and the discretion of the emergency physician.
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