Facial Fractures and Nasal Fractures: Evaluation and Management
Dr. Chang performs only nasal fracture repairs while Dr. Redmon performs additional fracture repairs EXCEPT for mandibular fractures.
Broken bones are scary, but broken bones of the face has a particularly unique psychological impact due to the fact that, well... it is the "face". It is what people look at. It is where you breath, see, talk, and eat from. As such, patients who have suffered a facial fracture are understandably concerned about what should be done.
Not All Facial Fractures Require Repair!
Just because something is broken does not mean surgery is required. The key elements that lead towards a decision for surgery are the following (not all-inclusive, but general pointers):
- Any functional deficit including inability to open and close the jaw.
- Change in your occlusion (the way your teeth come together).
- Double vision (blurry vision does not count).
- Cosmetic deformity (asymmetry) due to facial fracture (bruising and swelling does not count).
- Change in your ability to breath.
As a general rule, if the fracture does not affect form (facial symmetry) and function (see, breath, eat), than no surgery is required.
The reason why all broken legs need to be fixed is because it always affects function (walking).
The nice thing about facial fractures is that the skull acts like a natural cast preventing motion of the fracture pieces allowing for healing to occur. Other than the jaw, there are no other moving parts... which is probably why all jaw fractures require surgical repair (more on that below).
Facial Fracture Management
If a facial fracture is suspected, the best first thing to do is to ice it like crazy (20 min on, 20 min off in cycles throughout the day while awake), keep the head elevated (even when sleeping), and take motrin for any pain/discomfort.
These measures minimize and resolve any swelling and bruising as quickly as possible. If a broken nose is suspected, make an appointment with a plastic surgeon or ENT within 1-2 days. If there is concern for other facial fractures beyond a broken nose, go to the ER and make sure they get a CT of the maxillofacial (no contrast). Of note, a CT scan of the head is NOT the correct study which looks more at the brain rather than the face. Why not an x-ray? A CT scan, unlike an X-ray, provides a 3-dimensional picture of the fracture which is very important when assessing whether surgery is required and essential if surgical repair is pursued.
Facial Fracture Locations
On the CT scan, beyond exam findings regarding form and function, there are two basic findings that is specifically looked for when evaluating whether surgical repair is needed or not:
- bone fragment displacement
- location of fracture
Displacement is how far off alignment is the fracture. Ideally, if the fracture is "minimally" or "non" displaced, that's a good sign that suggests no need for fracture repair.
Displacement information in combination with the location of the fracture provides the rest of the information required when deciding whether surgery is needed or not.
Let's now go over fracture location considerations and repair methods. To skip to a specific fracture, see table.
The only reason to see a physician immediately or go to the ER after an injury to the nose is to assess whether a septal hematoma has formed. The septum is a wall that divides the right nasal cavity from the left. If a hematoma has developed (which is VERY rare), it needs to be drained in an approach similar to doing a deviated septum repair.
Regarding the "broken" nose itself...
It is my own personal opinion that getting an X-ray to look for an isolated broken nose is a waste of time and money. Perhaps the ONLY time I would think about getting it is for legal reasons (the victim plans to sue the assailant if applicable).
However, my standard spiel is one only does something about a nasal fracture (surgically) if there is a problem with:
- Function: Difficulty with nasal breathing due to fracture and not because of mucosal swelling
- Form: Cosmetically unacceptable to the patient once soft tissue swelling goes down all the way
Otherwise, you do nothing... even if it is clearly broken on X-ray (if one was obtained). If the answer is affirmative to one or both of the above, than you fix it. Therefore, why bother with the X-ray if it doesn't change management?
Keep in mind that the nasal bone is located on the top half of the nose. The bottom half of the nose is made of cartilage and if this is where the deformity is located, a nosejob may be required to correct rather than a nasal fracture repair.
If surgery is not required and the patient actively plays in a sport and wishes to continue playing, some type of protection is required as the nose is "broken" after all. Definitely wear a facemask if applicable (ie, ice hockey, football). If the sport does not use any type of headgear (ie, soccer, basketball, etc), than purchasing headgear specifically to protect the nose is highly recommended.
If surgery is required, the fractured pieces of bone are physically moved back in alignment using finger manipulation as well as instruments through the nostril. No incisions are required. A cast may be placed over the nose and needs to be kept in place for 2-3 weeks. Not uncommonly, nasal packing may be inserted into the nose to prevent the broken nasal fragments from falling back into the nasal cavity.
Orbital Fracture (Fractures Around the Eye)
These fractures involve the bone(s) that enclose the eye. It includes not just the rim that you can feel around the eye, but also the bone that holds the eye in place within the skull. The picture depicts the most common areas (purple) where orbital fractures are seen.
As with any facial fracture, an assessment of form and function needs to be made when deciding whether surgical repair is required or not.
- Function: Double vision (blurry vision does not count)
- Form: Cosmetic deformity present taking into account soft tissue swelling and bruising
Blurry vision is potentially indicative of damage to the eye itself sustained from the trauma. In this situation, ophthalmology evaluation is necessary sooner rather than later.
However, regardless whether blurry or double vision is present or not, it is important to see an ophthalmologist to ensure no hidden problems that may cause problems in the future (ie, traumatic glaucoma, optic neuritis, retinal detachment, etc).
If surgery is pursued, repair requires incisions to the face. Such incisions are demarcated in the image to the left. Red lines are incisions on the skin. Blue lines are special incisions that are hidden from view. Some or all these incisions may be required to completely repair orbital fractures.
Maxillary Sinus Fractures (Not Cheekbone Fractures)
These fractures are demarcated in purple to the right. The bone in this region is exceedingly thin and it does not take much force to cause it to break. And when it breaks, it may do so like an eggshell because of how thin it is. This fracture should not be confused with a cheekbone fracture which is discussed below.
It is quite rare that these fractures require surgical repair unless the fracture is massive in size. Even than, it is still rare to correct.
If repair is performed, it usually is due to nerve compression which may cause some pain or numbness to the cheek region. If sensation is present though decreased, the nerve is intact and repair is not absolutely necessary. The incision to approach these fractures is under the upper lip in the mouth.
The fracture pieces are typically just moved into normal position and than left alone. Plates or screws are not used to stabilize the bone given how thin it is. Trying to place a screw would be trying to insert a screw into an eggshell without breaking it (you just end up breaking it even more).
Zygomatic Fracture (Left)
This fracture (shaded in purple) is located right in front of the ear (behind the cheekbone) and is next to the joint of the jawbone which allows one to open and close the mouth. As such, fractures of the zygoma (shown by red line) typically requires repair as it does impair chewing (affect function) and worst case, prevents mouth closure.
The incision (green line) to correct this fracture is located above the ear within the hair. A blunt instrument (kind of looks like a butter knife) is threaded through this incision down the the fracture and pushed into alignment. A brace of some kind may be placed to hold the fracture segment in place. Rarely, a metal plate may be screwed into the bone to hold it even more securely.
Patients may suffer long-term TMJ after this type of fracture and as such, precautions should be taken after surgery in order to minimize this issue.
Tripod Fracture (Right)
Tripod fracture in its essence is a cheekbone fracture. It is a combination of zygomatic fracture and orbital fracture (red lines) resulting in a free-floating cheekbone (denoted by purple area).
This type of fracture almost always requires repair as it affects both form and/or function.
- Function: Jaw opening and closing
- Form: Droopy cheekbone resulting in facial asymmetry
Given both zygomatic and orbital components, multiple incisions are required for correction, standard ones being shown in green, but others may be required depending on fracture location. Small plates with screws are used to stabilize this type of fracture.
Mandible Fracture (Left)
These fractures are perhaps one of the most common fractures seen after a fight. It's also why martial artists clench their teeth when fighting as such fractures occur when the mouth is open when hit. Though mandible fractures can occur anywhere shaded purple, the most common locations where fractures are seen are shown by the red lines.
Clearly, function is affected as it will hinder a person's ability to chew food.
It's also one of the most uncomfortable facial fracture surgeries to recover from as often, the mouth needs to be wired shut as shown in the picture (mandibular-maxillary fixation). Why? It's so the upper jaw can act as a "cast" to allow for bone healing to occur. The reason this is important is so the bones heal in such way that the teeth comes together as normally as possible. Ideally, it will come together in exactly the same way as it did before the fracture occurred.
Incisions used to fix this type of fracture are all made under the lower lip inside the mouth. Plates with screws are often used for long-term stability. Given the nature of the fracture, teeth issues due to dental root damage as well as lower face numbness is not uncommon and potentially permanent.
LeFort fractures are probably the most severe fractures an individual can sustain to the face and typically occurs in car accidents when the patient was not wearing a seatbelt. There are three classes of LeFort fractures in order of increasing severity shown below. The classic sign that a LeFort fracture has occurred is when the the upper jaw (area shaded in by purple) can be moved freely from the rest of the face (floating upper jaw). These are modified images reproduced from Wikipedia.
LeFort Type 1
LeFort Type 2
LeFort Type 3
A patient may also have a combination of LeFort fractures (right LeFort 1 and left Lefort 3).
Surgical repair is always required and typically occurs during the hospitalization (given the patient often has sustained other trauma including brain injury). Depending on the LeFort type, incisions are typically made under the upper lip, within the lower eyelid, next to the nose, and temple region. The jaws are also wired shut for the same reason mandible fractures are
Who Performs Facial Fracture Repairs?
There are 3 types of surgeons who are trained to perform facial fracture repairs (but not all will do them).
- Oral-Maxillo Facial Surgeon
- Plastic Surgeon
- Otolaryngology - Head & Neck Surgeon
Related Blog Articles
- What To Do With a Broken Nose?
- Not All Facial Fractures Require Repair... Ask Anaheim Duck's Getzlaf
- US Gymnast Maroney Suffers Nasal Fracture
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