Facial fractures develop after various forms of trauma, with motor vehicle accidents, contact sports, and both accidental or intentional injuries being most common. Numerous anatomical sites may be a potential site for fracture, and multiple fractures are not uncommon, especially in the setting of more severe trauma. The diagnosis is made by a thorough physical examination and imaging studies.
Numerous anatomical structures of the face may be a site of fracture, which is why the clinical presentation may significantly vary. In general, trauma is the cause of fracture, but the mode of injury significantly changes across different age groups. In children, falls and contact sports are most important forms of trauma, whereas intentionally inflicted injuries and motor vehicle accidents are more prevalent among adults . Facial fractures are predominantly seen in males and the following sites may be involved :
•Frontal bone and the frontal sinus - Although considered to be one of the less common sites of facial fracture overall , infants and young children can suffer from severe injury of the frontal bone and the surrounding area due to its underdevelopment, and central nervous system injury may be one of the most important complications .
•Nasomaxillary area and the orbit - The zygomatic area, the nose and the orbit are the sites where fractures are predominantly encountered in clinical practice   . Periorbital edema, lower eyelid ecchymosis and subconjunctival hemorrhage presenting as a "bloodshot eye" are signs of orbital trauma and possible fracture , while visual deficits, facial widening, flattening of the malar region, enophthalmos and dental abnormalities are common signs when the entire area is affected . It must be noted that orbital and midfacial fractures carry a significant risk for blindness due to optic nerve injury . In addition, rhinorrhea, epistaxis or leakage of cerebrospinal fluid (CSF) may occur when fractures of the nose and cribriform plate are encountered . If not adequately managed, meningitis, sinusitis, as well as the development of a mucocele are known complications .
•Jaw fracture - Fractures of the mandibular condyle are also one of the most important sites of fracture in children, but damage to the jaw presenting with jaw pain, tenderness, facial asymmetry, deviation of the chin, displacement of the jaw and the teeth and paresthesias   may also occur.
Entire Body System
- Soft Tissue Swelling
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. [fauquierent.net]
Soft tissue swelling over orbital rim. Opacification of affected maxillary sinus. Displaced orbital floor (“trap door”). Polypoid density in roof of maxillary sinus through herniation of orbital contents. Cheek paresthesia if infraorbital canal [slideshare.net]
Radiographic signs of facial fractures Direct Signs nonanatomic linear lucencies cortical defect or diastatic suture bone fragments overlapping causing a “double-density” asymmetry of face Indirect Signs soft tissue swelling periorbital or intracranial [rad.washington.edu]
- Soft Tissue Mass
CT will, of course, show these fractures and soft tissue mass much better. [rad.washington.edu]
- Localized Edema
edema and poor patient compliance during initial examination. [ncbi.nlm.nih.gov]
Jaw & Teeth
Symptoms your child may have can include: pain excessive salivation difficulty swallowing. swelling malocclusion (improper meshing of the upper and lower jaw and teeth) skin discoloration visible jaw deformity nosebleed difficulty breathing lacerations [childrenshospital.org]
Symptoms of a broken jaw are: Pain in the jaw Malocclusion, which is an inability to put the teeth together A bruise or bruising under the tongue, which frequently indicates a broken jaw Maxillary or Midface Fractures Maxillary fractures may have similar [naturalfacedr.com]
Blurry or decreased vision Numbness in the forehead, eyelids, cheek, or upper lip/teeth Swelling of the cheek or forehead Broken jaw Pain Bruising, swelling, or tenderness along the jaw or below the ear Inability to bring the teeth together properly (malocclusion [webmd.com]
[…] zygomaticosphenoid suture important in anticipating overall alignment and orbital volume change fractures affecting dental occlusion (maxillary-mandibular tooth alignment) occlusion-bearing maxillary fractures, mandibular fractures as little as 2-3 mm of malocclusion [radiopaedia.org]
- Anterior Open Bite
Occlusion, look for anterior open bite and midfacial mobility. 3. Carefully inspect the dentition, remove any dental fragments from the mouth. 4. [medicine.uiowa.edu]
• Enophthalmos • CSF rhinorrhoea • Step deformity in the lower border of the orbit • Intact zygomatic bone and arch –Intraorally • Malocclusion • Gagging of the posterior teeth and anterior open bite • Mobility of the maxilla • Ecchymosis of the sulcus [slideshare.net]
Lefort 1 fractures most commonly present with an anterior open bite. Mandibular maximal opening can be limited in cases where the zygomatic arch is depressed and is impinging the rotational movement of the coronoid process. [link.springer.com]
- Difficulty Opening the Mouth
Jaw fractures often result in pain and difficulty opening the mouths and numbness in the lip and chin. Diagnosis & Tests Radiography, (imaging of tissues) using X-rays, or CT scans are used to rule out facial fractures. [texaschildrens.org]
Face, Head & Neck
[…] reduced by exerting firm, quick pressure with the thumbs toward the midline or by inserting a soft probe in the nares to elevate the depressed or deviated septum into anatomic position.  Ongoing management of these injuries consists of control of epistaxis [emedicine.medscape.com]
• Epistaxis. 3/12/2016 42 43. Intra-orally • Malocclusion. • Mobility of tooth bearing portion. • Dull sound on percussion. • Ecchymosis of the maxillary buccal sulcus. 3/12/2016 43 44. [slideshare.net]
In addition, rhinorrhea, epistaxis or leakage of cerebrospinal fluid (CSF) may occur when fractures of the nose and cribriform plate are encountered. [symptoma.com]
Epistaxis can be alarming, but is usually controlled with the following conservative measures: pinching the nasal ala against the septum topical vasoconstrictors (nasal decongestant) chemical cautery with silver nitrate. 6 If these measures fail, an epistaxis [racgp.org.au]
[…] and loss of vision - ocular rupture blow out fracture occurs when pressure directly applied to eye with fracture of inferior bony structures (enophthalmos, diplopia, impaired eye movement, infraorbital hypoesthesia) NASAL FRACTURES prime concerns are epistaxis [lifeinthefastlane.com]
- Facial Pain
Without treatment, your facial fracture may lead to uneven facial features, facial pain, eye pain, or blindness. You may have bleeding that blocks your airway, making it hard to breathe. [drugs.com]
The extent of injury may be quite severe and many patients suffer from multiple fractures of the face simultaneously, especially in severe forms of trauma, such as motor vehicle accidents. For this reason, a detailed patient history regarding the mode of injury and a thorough physical examination of the face is pivotal in the assessment of facial fractures. Firstly, a complete inspection and palpation of the face should reveal signs and symptoms that point to a fracture of a specific site, but because not all bones can be evaluated during the physical examination, implementation of various imaging studies should be the next step in workup . Plain radiography of the cranium is initially performed, but computed tomography (CT) provides a better view into the skeletal structures of the head. For this reason, it is considered to be the gold standard in the diagnosis of facial fractures  . Moreover, a panoramic CT is advocated in the setting of mandibular fractures, but the use of panoramic X-ray imaging as an adjunctive procedure has been well-established, especially when CT findings yield inconclusive results regarding dental injury .
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