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Midface fractures also known as Le Fort fracture occur because of high-energy blunt force to the face. Typical trauma includes motor vehicle accidents, altercations and falls.

The maxilla extends from the cranium and dental plane, aka the middle of the face. Its intimate association with the oral cavity, nasal cavity, and orbits and the multitude of structures contained within and adjacent to it make the maxilla a functionally and cosmetically important structure. Fracture of these bones are life-threatening as well as disfiguring. Timely repair of these fractures is a necessity to correct deformity and loss of function

Presentation of Types of Fractures

  1. Le Fort I: presents with upper lip swelling and numbness of the upper teeth. Percussion of the upper teeth results in a cracked pot sound.
  2. Le Fort II: edema of the soft tissue over the middle third of the face, bilateral orbital ecchymosis, subconjunctival hemorrhage, CSF rhinorrhea, diplopia and a bloody nose. There may or may not be numbness of the cheek.
  3. Le Fort III: tenderness of the frontal sinus, lengthening of the face, hooding of the eyes, and gagging from the side of the injury.

Diagnosis

History and physical exam suspect diagnosis. A CT is needed to confirm diagnosis.

Treatment

Treatment is surgical and is performed once all life-threatening injuries are stabilized.

Facial Fractures

Facial fractures are also called maxillofacial fractures, zygomatic fractures, orbital fractures, tripod fractures, quadripod fractures, ZMC fractures, Le Fort Fractures, maxilllary fractures, etc

Dear visitor, this is not going to be the same technical description of face fractures you see on the other sites, like Emedicine, WebMD, or Wikipedia.

This page is designed for practical use of what to do and what you need to know if you or your loved one ended up in the Emergency Room with face fracture. Here you will find the signs to watch out for, questions to ask, and instructions to follow after you go home.

The reason for this page is that I see a lot of mismanaged face fractures where the patients received a lot of papers from the hospital but are still confused on what to do.

What is face fracture? In most cases facial fracture can refer to any fracture of the bones of the face, usually including or excluding nose. Sounds confusing? You bet it is. Many different specialties are involved in the treatment of facial fractures, like plastic surgeons, ENT surgeons, ophthalmologists, oromaxillofacial surgeons, etc. Each of them introduces a somewhat different approach to the treatment of face fractures and that process creates a lot of confusion.

If you look at the picture of the human skull, there are several distinct areas on the face where the fractures can occur, like orbits, nose, cheek bones, upper jaw, lower jaw and forehead.

Depending on geography of the fractures, we can separate face fractures into several groups:

  1. orbital fractures – usually involve fractures of the orbits

  2. nasal fractures – usually involve fractures of the nose and/or septum, which is a structure separating right and left nostrils

  3. frontal sinus fractures – usually involve fractures of forehead bones

  4. ZMC fractures, zygomaticomaxillary fractures, also known as tripod fractures, or quadripod fractures, or maxillary fractures, or cheek bone fractures – these fractures involve the cheek bones upper dentoalveolar, or maxillary, or upper jaw fractures – usually involve upper jaw from the nose to the upper teeth

To learn more about a specific fracture above, please click corresponding page or link.

To make matter more confusing, there is also classification by Rene Le Fort. Rene Le Fort was a french surgeon who used cadaver heads. He would inflict traumatic injuries to them trying to determine more common patterns of face fractures. Today this type of experiments would not be allowed but in 1901 he described 3 patterns of face fractures, today known as Le Fort I, II, and III. This classification is not precise, it does not describe fractures very well but with lack of better system, it is still used today mostly for clinical purposes by surgeons.

Because there are so many different classifications and because even doctors are commonly confused about how to properly describe the fracture, many times patients get mistreated. The most common scenario is that the patient ends up in the emergency room after a car accident or fight or a fall and the CT scan is read by a radiologist who names a lot of different fractures. However, just naming the fractured bones does not give the ER doctor the information needed to make a decision on proper treatment. Especially if competent face fracture surgeon is not available, the patient is sent home with follow up instructions and if they do not see an experienced face fracture surgeon within 10 days or so, they may have permanent deformity or functional problem.

Unfortunately, in my practice I did see a few patients who eventually got to me too late. The point is, MAKE SURE YOU ARE SEEN BY A QUALIFIED FACE FRACTURE SURGEON WITHIN 1 WEEK OR SOONER.

In developed countries, the leading causes of facial fractures are motor vehicle accidents, interpersonal violence, and industrial accidents, falls and sports injuries.

Fractures of face bones, like any other fractures, is usually associated with pain at the fracture site, bruising, swelling of the surrounding tissues, step –off (a gap or unevenness when palpating the area, which may be difficult to identify because of swelling), nose bleeding, asymmetry or uneven position compared to the other side, changes in sensation or muscle movement, changes in vision, double vision, blurry vision, loss of vision (blindness) and many others.

The main diagnostic test is CT scan without contrast. Many centers still use plain x rays of the head but it is very easy to miss a fracture on those and for the surgical planning they are worthless. IF YOU THINK YOU COULD POSSIBLY SUFFER FROM A FACE FRACTURE, MAKE SURE YOU GET A CT SCAN AS SOON AS POSSIBLE.

About 10% or more patients with face fractures have associated but commonly missed neck injury. MAKE SURE THAT YOUR DOCTOR PROPERLY EXAMINES YOUR NECK TO MAKE SURE THAT YOUR NECK IS NOT INJURED. Most trauma centers will routinely perform CT of head, face and neck at the same time to make sure there are no associated injuries.

Here is a little secret, unless you are at a major trauma center, where you may or may not want to be, you may assume that the emergency doctor may not fully realize the complexity of your fracture unless the CT had been reviewed by a face fracture surgeon. The radiologist may be able to give the description of the fractures but the readings usually lack clinical recommendations.

Here are several signs that you need to see a face fracture surgeon:

  1. High force or impact injury with multiple fractures

  2. Face Fractures are associated with deep external lacerations

  3. Face Fractures are associated with numbness of any area of the face, including cheek, nose, or lip or gums areas

  4. Face Fractures associated with any changes in vision, blurry or double

  5. Face Fractures associated with visible external deformity or asymmetry either externally or on CT scan

  6. Face Fractures associated with difficulty looking up, down, right or left

  7. Face Fractures associated with pain of the eyeball itself or behind the eyeball – THIS IS VERY SUBTLE BUT IT IS ACTUALLY AND EMERGENCY BECAUSE YOUR MAY GO BLIND.

  8. Face Fractures when your teeth feel funny or do not match up, or they do match up but do not feel normal.

  9. Face Fractures when you cannot normally open or close your mouth or when it hurts to move the jaw

These are the questions you need to know answers for from the Emergency room before you leave the emergency room:

  1. Do I have more than one fracture? Is it displaced?

  2. Is there a chance that the muscle or other soft tissue is stuck in the fracture site?

  3. Is there injury to eyeball itself?

  4. Is there a nerve injury associated with my face fracture?

  5. Does my fracture cross through the opening of the nerve?

  6. What percentage of the orbital floor is injured? Is it over 20-25%?

  7. Is there a change of the orbital volume compared to the normal side?

If any one of the above answers is yes, I suggest you see a face fracture surgeon within 1 week if not sooner. In case of pediatric patient, as soon as 2-3 days.

I usually recommend the following home care regimen to most face fracture patients:

  1. Check tetanus immunization status. Even if you do not have external cuts, the
    fractures can be in contact with internal air spaces, which communicates with external
    environment, so immunization is needed.

  2. Oral antibiotics for 1 week or until seen by a face fracture surgeon

  3. Soft diet or liquid diet only until seen by a face fracture surgeon. Many fractures are
    not properly diagnosed in the ER and muscle movement can actually pull the fracture
    out of alignment during biting or chewing.

  4. Head of the bed elevation to reduce swelling

  5. Cool compresses to affected area. Do not use ice or ice packs or gloves packed with
    ice as they can cause frost bites and create more problems than they solve. I have seen
    it before. I suggest getting a face towel, or eye patches or 4×4 gauze, dipping it in
    ice cold water, putting into a Ziplock bag (so that the ice water does not run all
    over the bedding and pillows) and applying it continuously over 24-48 hours after
    the trauma.

  6. Do not strain your neck and relax it. Increased pressure may cause more swelling
    and bruising

  7. Keep your eyes closed and avoid straining them (for orbital and cheek bone fractures)

  8. Apply artificial tears drops to affected eye every 4 hour or more often if needed

  9. Apply 2 sprays of Ocean Nasal Spray (aka saline nasal spray) to each nostril
    every 4 hours and more often if needed. Cool moisture will promote reduction of
    swelling and removal of blood clots from inside the nose. You may notice some
    old blood clots come out and it is normal. But bright red blood is not.

  10. Avoid any activities that increase your blood pressure or promote increased blood
    flow to your head, like exercising, straining, coughing, lifting, bending forward,
    or sexual activity

  11. Every 4 hours monitor your vision for the first 24-48 hours. If the vision becomes
    worse, or you experience increasing or new pain in the eyeball or behind it, especially
    after episode of increased blood pressure, call the doctor immediately or go to the
    emergency room as it may be bleeding behind your eye that can lead to blindness.

  12. Get someone to be around for the first 48 hours. You might need help with medications,
    food or ice water or you might feel lightheaded as the result of associated concussion.
    I have seen patient falling at home after face fracture just to return to the hospital for another surgery

If you had been diagnosed with a face fracture within 1 week and would like to have Dr Volshteyn review the CT scan, please contact our office.

If your local hospital within New York – New Jersey area has hard time locating a face fracture surgeon who is able to see you in a timely fashion, please contact our office immediately. We gladly accept direct transfers to several major NJ hospitals in Monmouth, Middlesex and Hudson Counties.