Facial Fractures

Similar to patients with skull fractures, patients with an orbital, zygomatic (cheek), nasal, maxillary (mid face), or mandibular (jaw) fracture should be evaluated for a concussion, increased ICP, and a cervical spine injury. Patients with nasal, maxillary, and mandibular fractures may present with or develop airway management problems.

Orbital Fractures
Orbital Fracture S/Sx

• ± local swelling, bruising, & deformity, double vision, subconjunctival hematoma (left), numbness in cheek and/or gums, limited upward (middle) or downward movement of the eye (right).

• Air may become trapped in the soft tissue surrounding the eye (orbital emphysema) as a result of the traumatic event and often presents after sneezing.

Orbital Fracture Treatment

• Treat for concussion, ICP, and cervical spine injury as necessary. If none are present & vision is intact, begin a Level 3 EVAC. Surgery may be required.
• If vision is impaired, begin a Level 2 EVAC. Surgery is usually required.

Zygomatic (cheek) Fractures
Zygomatic Fracture S/Sx

• ± local swelling, bruising, and/or deformity.
• ± decreased sensation to the skin of the upper cheek, lateral nose, upper lip, & gums.
• ± concurrent orbital or maxillary fractures.

Zygomatic Fracture Treatment

• Treat for concussion, ICP, and cervical spine injury as necessary. If none are present, begin a Level 3 EVAC. Surgery may be required.

Nasal Fractures 
Nasal Fracture S/Sx

•  ± local pain, tenderness, swelling, crepitus, bleeding, deformity, bruising of nose or under eyes (black eye), lacerations, & difficulty breathing through nose; mouth breathing is common.
• The nose can visually appear straight but the septum can be internally deviated.

 Nasal Fracture Treatment

• Treat for concussion, ICP, and cervical spine injury as necessary. If none are present, consider a Level 3 EVAC. Reduction/repair is done within 72 hrs, 5-10 days after swelling has gone down, or repaired surgically after the initial damage has healed.
• Begin a Level 3 EVAC if pain or swelling remain after three days, the patient develops a fever, nasal breathing remains restricted after swelling goes down, or the patient’s nose is crooked.
• Treat for bloody nose (epistaxis) as necessary.
• Begin a Level 2 EVAC if CFS appears to be present: runny nose, salty postnasal discharge, or positive ring sign. If CFS is present in the pt’s blood, it will separate if the patient’s blood is placed on porous paper or cloth (coffee filter, gauze, etc.).

Maxillary (mid face) Fracture
Maxillary Fracture S/Sx

• ± local pain, tenderness, swelling, bruising, crepitus, bleeding, deformity, broken teeth, & difficulty breathing through nose or mouth.
• Patient’s bite may be affected.
• ± concurrent orbital, nasal, or zygomatic fracture.

Maxillary Fracture Treatment

• Clear airway and separately treat fractured or avulsed teeth.
• Treat for concussion, ICP, cervical spine injury, obstructed airway, and any concurrent orbital, nasal, or
• zygomatic Fx as necessary. If none are present, begin a Level 3 EVAC.
• Begin a Level 2 EVAC if obvious deformity is present; surgery is required.

Mandibular (jaw) Fracture
Mandibular Fracture S/Sx

• ± local pain, tenderness, swelling, bruising, crepitus, bleeding, deformity, broken teeth, asymmetrical bite, no ROM, & difficulty breathing through mouth.
• Ask the patient to bite down on a credit card or similar item between the teeth on each side of the patient’s jaw. The patient should be able to hold on to the card against mild resistance.

Mandibular Fracture Treatment

• Clear airway and separately treat fractured or avulsed teeth.Treat for concussion, ICP, cervical spine injury, and obstructed airway as necessary. If none are present, begin a Level 3 EVAC.
• Begin a Level 2 EVAC if obvious deformity is present, the patient is unable to hold a thin item between their teeth against resistance, or there is no range of motion in their jaw; surgery is required.

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