Emergency Medicine Clinics of North America
Volume 18 • Number 3 • August 2000
Copyright © 2000 W. B. Saunders Company
ORAL-FACIAL EMERGENCIES
ASSESSMENT OF PATIENTS WITH FACIAL FRACTURES
Edward Ellis III DDS
Kirk Scott 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
e-mail: eellis@mednet.swmed.edu
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.
PRELIMINARY ASSESSMENT
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%). [5]
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.
Airway
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.
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. [6] [11] [13] [15]
Examination of the
Maxillofacial Region
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:
- Do you see " double"? The presence of binocular diplopia can
indicate internal or periorbital fractures. It should be considered a
nonspecific symptom, however, because it can also be caused by other
things, most commonly periorbital edema. The presence of monocular
diplopia might indicate an injury to the globe, for which ophthalmologic
consultation is necessary.
- Are there any areas of numbness on your face? Any neurosensory deficit usually
indicates a skeletal fracture has occurred surrounding the bony
canals/grooves/foramina, through which the branches of the trigeminal
nerves exit.
- Does your bite feel " normal"? Most mandibular and/or maxillary
fractures are associated with the subjective feeling that the bite is not
"normal." The location of premature contact of the teeth can
help to direct the clinician to the site of fracture.
- Which areas on your face hurt? Although this question seems basic,
one could find a patient who points to a location that is not swollen or
bruised, such as the preauricular area, in the case of a condylar process
fracture of the mandible.
- Does it hurt when you open your mouth? Where? The presence of pain when one attempts
functional movements of the mandible can indicate that skeletal fractures
have occurred, although contusions of the temporomandibular joint can also
produce pain in the absence of skeletal fractures. If pain is present,
however, its location helps to determine underlying fractures. For
instance, preauricular tenderness with mandibular movement could indicate
a condylar process fracture. Pain at the angle of the mandible could
indicate a fracture in that location. Pain in the cheek region when one
attempts to open the mouth could signify a zygomaticomaxillary complex
fracture (discussed later).
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:
- Soft tissues
- Nerves
- Skeleton
- Dentition
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.
MAXILLOFACIAL FRACTURES
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.
Mandibular Fractures
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:
- Does your bite feel normal? Most mandibular (and maxillary)
fractures are associated with the subjective feeling that the bite is not
"normal." The location of premature contact of the teeth can
help direct the clinician to the site of fracture.
- Is your lip or chin numb? The inferior alveolar nerve runs
through the center of the mandible, from the middle of the ramus to the
mental foramen, where it exits to provide sensation to the lower lip and
chin (see Fig. 1). If the patient's lower lip and chin feel numb, it is
likely that there is a fracture on the side of numbness through the region
of the mandible where the inferior alveolar nerve courses.
- Does your jaw hurt? Where? A fracture of any bone causes
disruption of the innervated periosteum, and frequently hematomas that
further stretch the periosteum. The patient, therefore, has pain in the
region of the fracture. This is especially true during functional
movements of the mandible. The patient may state that his or her jaw hurts
when he or she opens the mouth. This occurs because the muscles that attach
to the mandible cause separation of the fracture(s) during functional
movements, causing pain. If the patient complains of pain in the
preauricular area, it is likely that a condylar/subcondylar fracture has
occurred, especially if this symptom is associated with a feeling that the
bite is abnormal. Temporomandibular joint contusions/hemarthroses also can
cause pain on functional movements in the absence of condylar fractures,
however.
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).
mages
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
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:
Does your bite feel normal? Most maxillary fractures are associated
with the subjective feeling that the bite is not "normal." The
location of premature contact of the teeth can help to direct the
clinician to the site of fracture. - Is your upper lip, side of nose,
or upper gingiva numb? The infraorbital and superior alveolar nerves provide sensation to
the maxillary teeth and gingiva, the upper lip, side of the nose, and
lower eyelid. If the patient has numbness to any of these structures, it
is likely that there is a fracture somewhere within the maxilla or orbital
floor.
- Does your jaw hurt? Where? A fracture of any bone causes
disruption of the innervated periosteum, and frequently hematomas that
further stretch the periosteum. The patient has pain in the region of the
fracture, which is especially true when teeth are clenched.
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.
Images
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.
Initial
Management
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.
Zygomatic Fractures
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:
- Does it hurt to open your mouth?
The
masseter muscle attaches to the zygomatic body and arch, and inserts onto
the mandibular ramus. When fractures of the ZMC occur, opening the mouth
causes contraction of the masseter muscle, pulling the zygoma inferiorly.
This causes pain and results in limitation of mandibular opening
(trismus). In rare cases, the zygoma can be displaced to the point of
impinging on the coronoid process of the mandible, limiting opening.
- Is your lower eyelid or upper
lip numb?
The infraorbital nerve courses along a canal in the floor of the orbit and
is usually disrupted during a ZMC fracture (see Fig. 14). This causes
numbness to the distribution of the infraorbital nerve (i.e., lower
eyelid, side of nose, and upper lip).
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.
Images
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).
Orbital Fractures
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 [16] and in 5% of zygomatico-orbital fractures by Livingston
and colleagues. [10] Ophthalmologic consultation was deemed
necessary in approximately 5% of 2,067 cases of zygomatico-orbital injuries
reported by Ellis and colleagues. [3] Ioannides et al found significant
ocular/adnexal injuries in 26% of orbital fractures. [8] Al-Qurainy et al prospectively performed ophthalmologic
examinations in 363 patients who had sustained midfacial fractures. [1] 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. [4] Al-Qurainy et al found that the severity
of diplopia was associated with the severity of midfacial injuries. [2] 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).
Images
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.
Initial
Management
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.
Nasal and Naso-orbital-Ethmoid
Complex Fractures
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.
Clinical
Examination
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.
Images
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).
Initial
Management
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. [12] 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. [14] 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. [9] [12] 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 Bone/Sinus Fractures
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.
Clinical
Examination
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).
Images
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).
Initial
Management
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. [7] Whether a formal ophthalmologic
consultation should be obtained depends on the initial findings and the
discretion of the emergency physician.
References
1. Al-Qurainy
IA, Stassen LF, Dutton GN, et al: The characteristics of midfacial fractures
and the association with ocular injury: A prospective study. Br J Oral
Maxillofac Surg 29:291, 1991
2. Al-Qurainy IA,
Stassen LF, Dutton GN, et al: Diplopia following midfacial fractures. Br J Oral
Maxillofac Surg 29:302, 1991
3. Ellis E, El-Attar
A, Moos KF: An analysis of 2,067 cases of zygomatico-orbital fracture. J Oral
Maxillofac Surg 43:428, 1985
4. Ellis E:
Fractures of the zygomatic complex and arch. In
Fonseca RJ, Walker RV, Betts NJ, et al (eds): Oral and Maxillofacial Trauma, ed
2. Philadelphia, WB Saunders, 1997, pp 571-652
5. Gussack GS,
Luterman A, Powell RW, et al: Pediatric maxillofacial trauma: Unique features
in diagnosis and treatment. Laryngoscope 97:925, 1987
6. Gwynn PP,
Carroway JN, Horton CE, et al: Facial fractures--associated injuries and
complications. Plast Reconstr Surg 47:225, 1979
7. Holt GR, Holt JE:
Incidence of eye injuries in facial fractures: An analysis of 727 cases.
Otolaryngol Head Neck Surg 91:276, 1983
8. Ioannides C, Treffers
W, Rutten M, Noverraz P: Ocular injuries associated with fractures involving
the orbit. J Craniomaxillofac Surg 16:157, 1988
9. Lewin W:
Gram-negative meningitis following head wounds. Br J Surg 35:266, 1948
10. Livingston RJ,
White NS, Catone GA, et al: Treatment of orbital fractures by an
infraorbital-transantral approach. J Oral Surg 33:586, 1975
11. Luce EA, Tubb TD,
Moore AM: Review of 1000 major facial fractures and associated injuries. Plast
Reconstr Surg 63:26, 1979
12. Maxwell JA, Goldware
SI: Use of adhesive in surgical treatment of cerebrospinal fluid leaks. J
Neurosurg 39:322, 1973
13. Merritt R,
Williams M: Cervical spine injury complicating facial trauma: Incidence and
management, Am J Otolaryngol 18:4, 1997
14. Morley TP, Hetherington
RF: Traumatic cerebrospinal fluid rhinorrhea and otorhea, pneumocephalus, and
meningitis. Surg Gynecol Obstet 104:88, 1957
15. Sinclair D,
Schwartz M, Grass J, et al: A retrospective review of the relationship between
facial fractures, head injuries, and cervical spine injuries. J Emerg Med
6:109, 1988
16. Turvey TA:
Midfacial fractures: A retrospective analysis of 593 cases. J Oral Surg 35:887,
1977