Frontal bone fractures are uncommon injuries resulting from high-energy mechanisms such as unrestrained motor vehicle crashes or assaults with blunt objects. The significant amount of force needed to fracture the thick frontal bone likewise increases the immediate risk of traumatic brain injury, additional facial fractures, and cervical spine injury. Concomitant craniofacial injuries are present in 56% to 87% of patients with frontal sinus fractures.25 Severe frontal fractures may extend to the temporal bones and require a hearing and facial nerve function evaluation. Otorrhea in this setting is a cerebrospinal fluid leak until proven otherwise.26 Ocular injuries can occur in up to 25% of patients with frontal bone fractures. The most common finding is an afferent pupillary defect, occurring in about 10% of patients.27
Lacerations typically overlie frontal sinus fractures. Careful exploration is needed to identify all fractures. Crepitus is frequently palpable with any sinus fracture. In cases of suspected fracture, obtain a head CT to evaluate the anterior and posterior tables as well as the underlying intracranial structures (Figures 259-7 and 259-8).
Forehead laceration overlying a frontal sinus fracture. [Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 3rd ed. © 2010, McGraw-Hill, New York.]
Frontal sinus fracture from patient in Figure 259-7. CT demonstrating fracture of the anterior table of the frontal sinus. [Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 3rd ed. © 2010, McGraw-Hill, New York.]
Because the dura is adherent to the posterior table, operative repair of through-and-through frontal sinus fractures is necessary to prevent pneumocephalus, cerebrospinal fluid leak, and infection. Consider rhinorrhea in any patient with a frontal bone fracture to be a cerebrospinal fluid leak until proven otherwise.26 Mucopyoceles, collections of pus that develop as a result from nasal ducts blocked by fracture, and cranial empyema can result. Oral antibiotics, such as first-generation cephalosporins or amoxicillin clavulanate, are recommended with any sinus fracture. The patient with an isolated anterior table fracture may be discharged with nasal and oral decongestants and appropriate follow-up with a facial surgeon (otolaryngologist, plastic surgeon, or ophthalmology). Admit patients with depressed fractures for IV antibiotics and operative repair.
The orbit is traditionally thought of as a four-walled structure. It is made up of the frontal bone superiorly, the zygoma and sphenoid bones laterally, the zygoma and maxilla inferiorly, and the thin-walled lamina papyracea of the ethmoid bone medially. There are two categories of orbital fractures: pure, blow-out fractures and unpure, orbital fractures. The pure orbital blow-out fracture involves only the orbital walls and occurs when an object of small diameter strikes the globe without causing an orbital ridge or rim fracture. Force transmitted through the fluid-filled globe results in a fracture of the weaker inferior or medial orbital walls. Adipose tissue, the inferior rectus, or the inferior oblique can then herniate and become entrapped within the maxillary or ethmoid sinus (Figure 259-9). Lateral, inferior, and superior orbital ridge fractures typically occur with other facial fractures. Significant force applied to the nasal bridge can result in naso-orbito-ethmoid fractures that are often accompanied by injury to the lacrimal duct, dural tears, and traumatic brain injury.
Blow-out fracture findings, including fluid in the maxillary sinus, herniated fat or muscle, and delayed enophthalmos, occur with orbital floor fracture. [Reproduced with permission from Scaletta TA, Schaider JJ: Emergency Management of Trauma, 2nd ed. © 2001, McGraw-Hill, Inc., New York.]
Several key physical examination findings suggest orbital fracture. Enophthalmos occurs with herniation of globe contents before significant edema. Carefully palpate the entire orbital rim to detect any step-off deformity or crepitus. Infraorbital anesthesia often occurs with fracture of the orbital floor. Diplopia on upward gaze occurs with entrapment of the inferior rectus, inferior oblique, or orbital fat, or from injury of muscles or the oculomotor nerve. Naso-orbito-ethmoid fractures result in pain on eye movement, traumatic telecanthus, epiphora (tears spilling over the lower lid), and cerebrospinal fluid leak.28
Radiographic findings consistent with orbital fracture are seen in Figure 259-10. Additional findings include air-fluid levels or opacification of the maxillary sinus. Obtain a facial or orbital CT with axial and coronal sections to plan surgical management in patients with positive findings on a Waters' view or as the initial study in patients with significant clinical findings (Figure 259-11).
Blow-out fracture. Waters' view with teardrop sign (arrow) and fluid in right maxillary sinus (arrowhead). [Reproduced with permission from Knoop K, Stack L, Storrow A: Atlas of Emergency Medicine, 2nd ed. © 2002, McGraw-Hill, New York.]
Left zygomatic maxillary complex and right blow-out fractures. Disruption of zygomatic frontal suture and maxillary sinus on left (arrowheads) with herniation of orbital contents into maxillary sinus on the right (arrow) on face CT coronal section.
The patient with an isolated orbital fracture requires treatment with oral amoxicillin-clavulanate to treat sinus pathogens, decongestants, and instructions to avoid nose blowing until the defect has been repaired. Specialty consultation before discharge is important because controversy continues regarding the best time and indications for operative repair. Repair may be delayed 1 to 2 weeks in adults, whereas children require a shorter time for follow-up and repair. Naso-orbito-ethmoid fractures require admission for specialty consultation with facial surgery and neurosurgery.
Emergent ophthalmology consultation is required for associated ocular injury. Retrobulbar hematoma or malignant orbital emphysema may create an ocular compartment syndrome, resulting in an acute ischemic optic neuropathy (Figure 259-12). Physical examination findings include exophthalmos, decreasing visual acuity, and increased intraocular pressure. Emergency lateral canthotomy reduces ocular pressure and ischemia. Orbital fissure syndrome results from a fracture of the orbit involving the superior orbital fissure with injury to the oculomotor and ophthalmic divisions of the trigeminal nerve. Physical examination findings include paralysis of extraocular motions, ptosis, and periorbital anesthesia. Orbital apex syndrome occurs when the optic nerve is also involved, resulting in the preceding physical examination findings and diminished visual acuity.
Retrobulbar hematoma. CT of patient in Figure 259-2 demonstrates right retrobulbar hematoma. [Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 3rd ed. © 2010, McGraw-Hill, New York.]
The prominent location of the zygoma results in frequent fractures. Zygomatic arch fractures occur when an anterior and lateral force is applied typically from a fist or blunt object. The less common zygomaticomaxillary (or "tripod") fracture results classically from a high-energy deceleration injury with disruption of the zygomaticofrontal suture, zygomaticotemporal junction, and infraorbital rim (Figures 259-13 and 259-14). Because the zygoma forms the inferior and lateral walls of the orbit and superior and lateral roof of the maxillary sinus, zygomaticomaxillary fractures are considered orbital and sinus fractures.
Tripod fracture locations. Zygomatic arch fracture (1), lateral orbital rim fracture (2), inferior orbital rim fracture (3), and lateral wall of maxillary sinus fracture (4). [Reproduced with permission from Schwartz DT: Emergency Radiology: Case Studies. © 2008, McGraw-Hill, New York.]
Zygomatic maxillary complex fracture. Face CT with three-dimensional reconstructions demonstrating right tripod fracture.
On physical examination, flattening of the malar eminence will be noted in the absence of often significant swelling (Figure 259-1). The eye may appear to tilt as the lateral canthus is pulled inferiorly, often with a large lateral subconjunctival hemorrhage. Trismus results from masseter spasm or mechanical impingement of either the temporalis muscle or coronoid process of the mandible. Place a finger adjacent to the maxillary molars and palpate the posterior surface of the arch for tenderness or loss of the space compared to the uninjured side. Diplopia, infraorbital anesthesia, and crepitus occur with significant orbital and sinus involvement. Facial CT is needed to define the extent of the injury.
Patients with isolated temporal arch fractures can be discharged with appropriate medications and follow-up. Patients with zygomaticomaxillary fractures with any loss of vision or significant displacement require admission for IV antibiotics and operative repair.
Midfacial fractures can be caused by motor vehicle crashes, sports, assault, and falls due to seizures or intoxication or in the elderly. The incidence of midfacial fractures in motor vehicle crashes has declined significantly due to improvements in vehicle restraint systems.29 Fractures of the maxilla require a significant force such as an unrestrained motor vehicle crash patient whose face strikes the dashboard or the severely battered patient.
Le Fort injuries often present dramatically, with significant hemorrhage, early swelling, bilateral orbital ecchymosis, and cerebrospinal fluid leaks in Le Fort II and III injuries. Each pattern results in a unique movement of the midface while gently rocking the hard palate with one hand and stabilizing the forehead with the other hand (Figure 259-15). Le Fort I is a transverse fracture separating the body of the maxilla from the pterygoid plate and nasal septum. Only the hard palate and teeth move, similar to a loose upper denture. Le Fort II is a pyramidal fracture through the central maxilla and hard palate. Movement of the hard palate and nose occurs, but not the eyes (Figure 259-16). Le Fort III is craniofacial dysjunction when the entire face is separated from the skull from fractures of the frontozygomatic suture line, across the orbit and through the base of the nose and ethmoids. The entire face shifts with the globes held in place only by the optic nerve. A Le Fort IV fracture includes characteristics of the Le Fort III and also involves the frontal bone. CT scan of the face with coronal and axial slices with three-dimensional reconstructions best defines these complex injuries.
Le Fort injury patterns. Illustration of the fracture lines of Le Fort I (alveolar), Le Fort II (zygomatic maxillary complex), and Le Fort III (craniofacial dysjunction) fractures. [Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 3rd ed. © 2010, McGraw-Hill, New York.]
Bilateral Le Fort II fractures. Face CT with three-dimensional reconstructions demonstrating bilateral Le Fort II in a panfacial fracture patient (arrows).
Patients with Le Fort injuries often present with significant hemorrhage, requiring airway protection and nasal packing. Oral packing is often required for control of fractures involving the hard palate. Le Fort injuries require admission for management of significant associated injuries, IV antibiotics, and surgical repair.
Mandible fractures are the second most common facial fracture after nasal fractures. Assaults, motor vehicle crashes, and falls are the most commonly reported mechanisms.30 One large trauma center reported 36% of fractures in the region of the angle, followed by 21% in body, and 17% in the parasymphyseal region.31 Always look for multiple mandibular fractures with one injury at the site of impact and a second subtle injury on the opposite side of the ring. In fact, a mandibular fracture should be considered bilateral until proven otherwise. Comminuted mandible fractures could result in upper airway obstruction due to the tongue being unsupported anteriorly. Presume an open fracture until a thorough intraoral examination determines otherwise. Fractures are classified as either favorable or unfavorable, depending on whether the musculature reduces or opens the fracture.
Patients with mandible fractures usually complain of malocclusion with pain worsened by attempted movement. On inspection, the mandible may appear widened or displaced to one side. Patients may present with trismus due to pain and swelling. Palpation reveals loss of the smooth counters of the mandible, tenderness, and anesthesia in the distribution of the proximal inferior alveolar or distal mental nerve. A careful intraoral examination is important to exclude small breaks in the mucosa seen with open fractures, sublingual hematoma or ecchymosis, and dental or alveolar ridge fractures and to identify missing teeth. Examine the ears for evidence of tympanic membrane perforation, hematotympanum, or evidence of condyle displacement. Place a finger into the external auditory canal and ask the patient to open and close the mouth to palpate for injury to the condyle.
Panorex remains the initial imaging study in patients with a low clinical suspicion of injury (Figure 259-17). Order mandible or face CT with coronal and axial sections in patients suspected of having condyle fractures, complex fractures, or multiple facial fractures (Figure 259-18). A chest radiograph is necessary in the unconscious patient with missing teeth to exclude aspiration of the missing teeth.
Mandible fracture. Panoramic view demonstrating an unfavorable mandibular fracture with obvious misalignment (arrow) due to the distracting forces of the masseter muscle. [Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 3rd ed. © 2010, McGraw-Hill, New York.]
Mandibular condyle fracture—right (A) and left (B). Face CT with three-dimensional reconstructions demonstrating right mandibular condyle fracture (A) and left mandibular fracture (B) in patient with zygomatic maxillary complex fracture in Figure 259-14.
In the patient with a stable airway, placement of a Barton's bandage, an ace wrap over the top of the head and underneath the mandible, will stabilize the fracture and help relieve pain. Administer pain control and antibiotics, such as penicillin G 2 to 4 million units IV (or clindamycin, 600 to 900 milligrams, in penicillin-allergic patients), for open fractures. Although studies question the utility of antibiotics, given the overwhelming number of potentially virulent oral anaerobes contaminating open mandible fractures, antibiotics remain a logical therapeutic agent.32,33 Patients with closed fractures may be given urgent outpatient follow-up. Open fractures require admission for operative repair.
Facial fractures in the pediatric population are typically due to falls, bicycle accidents, pedestrian accidents, and transport accidents. The nasal bones and mandible are most commonly fractured.34 Several unique considerations must be made in the initial management of the pediatric patient with facial trauma. Cricothyrotomy is contraindicated in patients <8 years old because the cricothyroid membrane is not developed until age 8 and should be avoided in those between 9 and 12 years of age. In children with severe midfacial injury in whom oral endotracheal intubation is not possible, laryngeal mask airway placement or needle cricothyrotomy serves as a temporizing measure pending emergency tracheostomy. Facial trauma in children should always prompt the consideration of child abuse.
Skull development predisposes children to certain facial and associated injuries while making others less likely. The child's high center of gravity, relatively poor balance, explorative nature, and prominent forehead make the child more susceptible to frontal bone impact and underlying brain injury. Cervical spine injury in children occurs at higher levels and more often without bony radiographic injury (spinal cord injury without radiologic abnormality). The maxillary sinuses do not begin developing until age 6 years old, which reduces the incidence of midfacial fractures compared with adults.
The pliable pediatric orbital floor is more likely to bend and crack, forming a small "trapdoor" through which muscle and fat become entrapped and potentially ischemic.35 Pediatric mandible fractures are more likely to be incomplete fractures and more irregular secondary to the underlying developing teeth.36 Rapid bone remodeling in children with callous formation begins within 1 week and makes delayed reduction difficult. Children with mandible fractures require prompt diagnosis and 1- to 2-day referral to a pediatric facial surgeon to prevent long-term problems with asymmetrical facial growth, cosmetic deformities, and difficulty with mastication.37