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.

A note and special information on facial fractures from Boris Volshteyn, MD, board certified plastic surgeon:

Dear visitor,

This is not going to be the same technical description of facial fractures found on other sites, such as 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 facial fractures. Here, you will find the signs to watch out for, questions to ask, and instructions to follow after you go home.

I see a lot of mismanaged face fractures.  Patients leave the hospital after an injury like this with a huge stack of papers and a lot of confusion on how to proceed.  

What is a facial fracture?

If you look at an illustration of the human skull, there are several distinct areas on the face where the fractures can occur such as the eye area (orbits), nose, cheek bones, upper jaw, lower jaw and forehead.

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

Orbital fractures – Fractures of the orbits (the bones surrounding the eye)

Nasal fractures – Fractures of the nose and/or septum, which is a structure separating the right and left nostrils

Frontal sinus fractures- Fractures of forehead bones

Zygomaticomaxillary fractures (ZMC fractures) - also known as tripod fractures, quadripod fractures, maxillary fractures, or cheek bone fractures – these fractures include the cheek bones, upper teeth, or upper jaw usually involving the 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 matters more confusing, there is also classification by Rene Le Fort, a french surgeon who utilized cadaver heads to research and treat different types of fractures in the early 20th century. He would inflict traumatic injuries to the cadavers to determine more common patterns of facial fractures. Today these types of experiments would not be allowed.  In 1901 he described three 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 a better system, it is still used today by surgeons mostly for clinical purposes.

Since there are so many different classifications and doctors are commonly confused about how to properly describe the fracture, many times patients do not receive proper treatment. The most common scenario is that the patient ends up in the emergency room after a car accident, fight, or a fall. Then multiple fractures are named by the radiologist reading the CT scan, however this does not give the ER physician the proper information to make the decision for treatment of the injuries.  Especially if a a facial reconstruction specialist is not available. The patient is usually advised to follow up with an experienced facial fracture surgeon and sent home with follow up instructions. If the patient does not see an experienced facial fracture surgeon within 10 days or so, they may have permanent deformity or functional problem.

Unfortunately, in my practice I have seen many patients that waited too long to seek treatment. PLEASE MAKE SURE YOU ARE SEEN BY A QUALIFIED FACIAL FRACTURE SURGEON WITHIN 1 WEEK OR SOONER.

What are some of the symptoms of facial fractures?

Fractures of facial bones, like any other fractures, are usually associated with pain at the fracture site, bruising, swelling of the surrounding tissues, a step –off (a gap or unevenness when touching 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) as well as many others.

What is the best way way to diagnose facial fractures?

The main diagnostic test is a CT scan without contrast. Many centers still use plain x rays of the head, however it is easy to overlook a fracture and impossible to plan any surgical treatment with regular x rays. IF YOU THINK YOU HAVE POSSIBLY SUFFERED A FACIAL FRACTURE, GET A CT SCAN AS SOON AS POSSIBLE.

Also, about 10% or more of patients with facial fractures have an associated, often 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 a 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, it is safe to assume that the emergency doctor may not fully realize the complexity of your fracture, unless the CT has been reviewed by a facial 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 you need to see a facial fracture surgeon if your your injuries are associated with;

• High force or impact injury with multiple fractures

• Deep external lacerations

• Numbness of any area of the face, including cheeks, nose, lip, or gums

• Changes in vision, blurry or double vision

• Visible external deformity or asymmetry either externally or on CT scan

• Difficulty looking up, down, right or left

• Pain of the eyeball itself or behind the eyeball – THIS IS VERY SUBTLE BUT IT IS AN EMERGENCY- BLINDNESS CAN OCCUR.

• Teeth feel funny, do not match up, or they do match up but do not feel normal

• Mouth cannot normally open or close or it hurts to move the jaw

Before you leave the emergency room, ask the following questions:

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 facial fracture surgeon within 1 week if not sooner. In the case of a pediatric patient, as soon as 2-3 days.

Recommended home care following facial fractures:

• 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.

• Oral antibiotics for 1 week or until seen by a facial fracture surgeon

• Soft diet or liquid diet only until seen by a facial 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.

• Sleep with head elevated to reduce swelling

• Cool compresses to affected area. Do not use ice or ice packs or anything packed with ice as they can cause frost bite and create more problems. I suggest using a small towel, eye patches, or 4×4 gauze dipped in ice cold water and sealed into a Ziplock bag, applying it continuously over 24-48 hours after the initial trauma.

• Do not strain your neck. Keep it as relaxed as possible. Increased pressure may cause more swelling and bruising

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

• Apply ‘artificial tears’ drops to affected eye every 4 hour or more often if needed

• 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 normal

• Avoid any activities that increase your blood pressure or promote increased blood
  flow to your head such as exercising, straining, coughing, lifting, bending forward,
  or sexual activity

• For the first 24-48 hours, check your vision every 4 hours. If your vision becomes
  worse, or you experience increased or new pain in or behind the eyeball, especially
  after an episode of increased blood pressure, call the doctor immediately or go to the
  emergency room as it may be bleeding behind your eye, possibly leading to blindness.

• It is important not to be alone during the first 48 hours after injury. Have someone stay with you 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. Sometimes patients fall at home after a facial fracture resulting in a return trip to the hospital for further surgery or treatment.

If you had been diagnosed with a facial fracture within 1 week and would like to have Dr Volshteyn review the CT scan, please contact our office 732-641-3350

If your local hospital within the New York, New Jersey area is having difficulty locating a facial 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. 732-641-3350

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