Facial Fracture Management in the Emergency Department Clinical Presentation

Updated: May 08, 2020
  • Author: Thomas Widell, MD; Chief Editor: Steven C Dronen, MD, FAAEM  more...
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The first priority is to perform a primary survey and attend to ABCs, as maxillofacial fractures are caused by significant trauma, [4, 5, 6, 7]  as well as gross neurologic function and control of the cervical spine.

Once life-threatening issues are addressed, obtain a thorough history, such as the following: allergies, medications, past medical history, last meal, events leading to injury.

Ask specific questions regarding injury, such as the following:

  • What was the mechanism of injury?

  • Did the patient lose consciousness?

  • Has the patient had any visual problems, such as double or blurred vision? [27]

  • Has the patient had any hearing problems, such as decreased hearing or tinnitus?

  • Do teeth come together normally (normal occlusion)?

  • Is patient able to bite down without pain?

  • Does the patient have areas of numbness or tingling on the face?

  • In women, ask if the injury was from a partner or if they feel threatened by anyone.

  • In children, ask questions to determine if child abuse is an issue.




Complete examination of the face is necessary, since multiple injuries easily occur. Below, portions of the examination specific for facial bones are marked with an asterisk (*) [28] :

  • Inspect face for asymmetry, which is often easiest to do looking down from the head of the bed.*

  • Inspect open wounds for foreign bodies and palpate for bony injury.*

  • Palpate the bony structures of the supraorbital ridge and frontal bone for step-off fractures.

  • Thoroughly examine eyes for injury, abnormality of ocular movements, and visual acuity.* [27, 29]

  • Inspect nares for telecanthus and widening of the nasal bridge, and palpate for tenderness and crepitus.*

  • Inspect nasal septum for septal hematoma and clear rhinorrhea, which may suggest a CSF leak.*

  • Palpate zygoma along its arch as well as its articulations with the frontal bone, temporal bone, and maxillae.*

  • Check facial stability by grasping teeth and hard palate and gently pushing back and forth, then up and down, feeling for movement or instability of midface.*

  • Inspect teeth for fracture and bleeding at the gum line (a sign of fracture through the alveolar bone), and test for stability.*

  • Check teeth for malocclusion and step-off.* Inspect for bleeding between teeth at the gum line (a sign of mandibular fracture).

  • Palpate mandible for tenderness, swelling, and step-off along its symphysis, body, angle, and condyle anterior to the ear canal.

  • Evaluate supraorbital, infraorbital*, [30] inferior alveolar, and mental nerve distributions for hypesthesia or anesthesia.

  • Nasal bone fractures: A nasal bone fracture is diagnosed by a history of trauma with swelling, tenderness, and crepitus over the nasal bridge. The patient may have had epistaxis that has resolved, but no clear fluid (CSF) should be present.

  • Nasoethmoidal (NOE) fractures: Suspect NOE fractures if the patient has evidence of a nasal fracture with telecanthus, widening of the nasal bridge with detached medial canthus, and epistaxis or CSF rhinorrhea.

  • Zygoma fracture: Physical findings of a depressed malar eminence with tenderness suggest a zygoma or zygomatic arch fracture. Often, edema is marked, which can obscure the depression. The patient may complain of pain in the cheek on movement of the jaw. The patient may have trismus or difficulty opening the mouth from impingement of the temporalis muscle as it passes under the zygoma. [15]

  • Tripod fracture: Suspect tripod fracture after blunt force to the cheek with physical findings of marked periorbital edema and ecchymosis. Malar flattening may be seen early, but marked swelling of overlying tissues often obscures this finding. Lateral canthus may be depressed if the zygoma is displaced inferiorly. Hypesthesia of the infraorbital nerve often is present, because the fracture extends through the orbit into the zygomaticomaxillary area where the nerve exits. Palpating the zygomaticomaxillary arch from inside the mouth may reveal a step-off fracture. A step-off may be noted at the zygomaticofrontal suture or on the zygomatic arch as well. Eye injuries may be associated with these fractures; thus, a thorough eye examination is important to document and act upon. [27]

  • Le Fort I fractures: Physical findings include facial edema and mobility of the hard palate. This is evaluated by grasping the incisors and hard palate and gently pushing in and out.

  • Le Fort II fractures: Findings include marked facial edema with telecanthus, bilateral subconjunctival hemorrhages, and mobility of the maxilla. Epistaxis or CSF rhinorrhea may be noted.

  • Le Fort III fractures: Findings include the appearance of facial elongation and flattening (ie, dishface deformity). Maxilla often is displaced posteriorly, causing an anterior open bite. Grasping the teeth and hard palate and gently moving them results in movement of all facial bones in relation to the cranium. CSF rhinorrhea is almost always present but may be obscured by epistaxis.