Facial bone fractureMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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572 items

☷ Legend

01Approach to the Critical Patient/attcp79

Immediate threats

›Primary survey priorities

›Airway obstruction risk

›Massive midface instability

›Expanding oral cavity bleeding

›Tongue base collapse with mandibular fracture

›Vomit and blood aspiration

›Breathing threats

›Concomitant pneumothorax

›Aspiration

›Circulation threats

›Hemorrhagic shock from associated injuries

›Facial hemorrhage with hemodynamic instability

›Neurologic threats

›Traumatic brain injury co-injury

›Cervical spine injury co-injury

›Vision threats

›Orbital compartment syndrome

›Globe injury

›Traumatic optic neuropathy

Airway strategy

›Airway planning in facial trauma

›Difficult airway anticipation

›Limited mouth opening

›Distorted anatomy

›Active bleeding

›Mandibular instability

›Oxygenation and suction readiness

›Two large-bore suction setup

›Apneic oxygenation nasal cannula if feasible

›Intubation options

›Rapid sequence intubation with video laryngoscopy if anatomy permits

›Awake technique if impending obstruction and cooperative

›Surgical airway if unable to ventilate or intubate

›Triggers for immediate surgical airway

›Inability to oxygenate

›Inability to ventilate

›Progressive obstruction with failed intubation

Hemorrhage control

›Bleeding control priorities

›Direct pressure and packing

›External laceration pressure dressing

›Oropharyngeal packing with airway protection

›Nasal hemorrhage measures

›Topical vasoconstrictor

›Anterior nasal packing

›Posterior packing if uncontrolled and airway protected

›Massive transfusion considerations

›Hemodynamic instability despite initial resuscitation

›Ongoing brisk bleeding

›Tranexamic acid considerations

›Major trauma with suspected significant hemorrhage

›Administration within 3 hours of injury

Vision-threatening emergencies

›Immediate eye threats

›Orbital compartment syndrome features

›Rapid vision decline

›Proptosis

›Firm orbit

›Relative afferent pupillary defect

›Retrobulbar hematoma actions

›Emergent ophthalmology activation

›Lateral canthotomy and cantholysis if vision threatened and delay expected

›Globe rupture concern

›Rigid eye shield

›Avoid ocular pressure

›Urgent ophthalmology activation

Consult and team activation

›Early specialty activation

›Maxillofacial surgery or ENT or plastic surgery for unstable patterns

›Le Fort fractures

›Open mandibular fractures

›Naso-orbito-ethmoid injuries

›Frontal sinus posterior table injuries

›Ophthalmology for orbital injury or vision symptoms

›Diplopia with entrapment concern

›Visual acuity change

›Relative afferent pupillary defect

›Neurosurgery for skull base fracture or intracranial injury

›CSF leak concern

›Depressed frontal bone or posterior table fracture

›Anesthesia for predicted difficult airway

›Active bleeding

›Severe midface disruption

02History/hx57

Mechanism and timing

›Injury context

›Mechanism

›Assault

›Fall

›Motor vehicle collision

›Sports injury

›Time of injury

›Hours since injury

›Delayed swelling progression

›Energy and vectors

›High-energy impact

›Direct blow to mandible

›Blow to zygoma

›Blow to orbit

›Penetrating injury

›Foreign body concern

›Blast mechanism

Symptoms and red flags

›Functional symptoms

›Malocclusion

›New bite change

›Tooth contact asymmetry

›Trismus

›Limited mouth opening

›Dental symptoms

›Loose teeth

›Missing teeth

›Facial sensory changes

›Infraorbital numbness

›Mental nerve numbness

›Nasal symptoms

›Epistaxis

›Nasal obstruction

›Clear rhinorrhea

›Ocular symptoms

›Diplopia

›Blurry vision

›Eye pain

›Neurologic symptoms

›Loss of consciousness

›Amnesia

›Vomiting

›Headache

Comorbidities and medications

›Bleeding risk factors

›Anticoagulants

›Warfarin

›Direct oral anticoagulants

›Antiplatelets

›Aspirin

›P2Y12 inhibitor

›Liver disease

›Coagulopathy risk

›Infection risk factors

›Diabetes mellitus

›Immunosuppression

›Tetanus immunization status

›Unknown or out of date

›Up to date

03Physical Exam/exam80

Primary maxillofacial exam

›Global facial inspection

›Facial asymmetry

›Malar flattening

›Step-off deformity

›Soft tissue injury

›Lacerations

›Contusions

›Expanding hematoma

›Epistaxis

›Persistent bleeding

›Clear rhinorrhea

›CSF leak concern

›Palpation and stability

›Midface mobility

›Le Fort pattern concern

›Zygomatic arch tenderness

›Trismus association

›Mandible tenderness

›Pain with movement

›Crepitus and step-offs

›Orbital rim

›Nasal bridge

›Zygomaticomaxillary buttress

Eye and orbit

›Vision screen

›Visual acuity

›Baseline comparison if available

›Pupils

›Relative afferent pupillary defect

›Extraocular movements

›Movement restriction

›Pain with gaze

›Diplopia pattern

›Upgaze limitation

›Downgaze limitation

›Orbital injury signs

›Proptosis

›Tense orbit

›Subconjunctival hemorrhage

›360-degree involvement concern for globe injury

›Hyphema

›Vision threat

›Chemosis

›Orbital injury marker

›Entrapment concern

›Oculocardiac reflex features

›Bradycardia with eye movement

›Nausea with gaze

Oral cavity and occlusion

›Occlusion assessment

›Malocclusion

›Open bite

›Crossbite

›Tooth injury

›Avulsion

›Fracture

›Intraoral lacerations

›Open fracture marker

›Mandible function

›Trismus severity

›Interincisal distance reduction

›TMJ tenderness

›Condylar injury concern

›Floor of mouth hematoma

›Airway risk

Neuro and neck

›Cranial nerve screen

›CN II vision and field concern

›CN III IV VI extraocular motility

›CN V facial sensation

›V1

›V2

›V3

›CN VII facial movement

›Cervical spine evaluation

›Midline neck tenderness

›Neurologic deficit

›High-risk mechanism

PITFALLS

›High-risk misses

›Normal external appearance with significant midface fracture

›Pediatric trapdoor orbital fracture with minimal bruising

›Delayed vision loss from orbital compartment syndrome

›Malocclusion as the key sign of mandibular fracture

04Differential Diagnosis/ddx38

Facial fracture patterns

›Common facial fractures

›Nasal bone fracture (ICD-10 S02.2)

›Septal hematoma complication

›Orbital floor fracture (ICD-10 S02.3)

›Entrapment

›Enophthalmos risk

›Zygomaticomaxillary complex fracture (ICD-10 S02.4)

›Infraorbital nerve dysfunction

›Maxillary fracture including Le Fort patterns (ICD-10 S02.4)

›Midface instability

›Mandibular fracture (ICD-10 S02.6)

›Condylar fracture

›Angle fracture

›Symphyseal fracture

›Frontal sinus fracture (ICD-10 S02.1)

›Posterior table injury

›Outflow tract injury

Vision-threatening and neurovascular conditions

›Eye emergencies in facial trauma

›Retrobulbar hematoma

›Orbital compartment syndrome

›Globe rupture

›Open globe

›Traumatic optic neuropathy

›Sudden vision loss

›Skull base injuries

›Basilar skull fracture (ICD-10 S02.1)

›CSF leak

›Intracranial hemorrhage

›Epidural hematoma

›Subdural hematoma

Mimics and associated injuries

›Non-fracture conditions

›Dental abscess

›TMJ dislocation

›Facial cellulitis

›Associated trauma patterns

›Cervical spine fracture

›Rib fractures

›Long bone fractures

05Laboratory Tests/lt18

Hemorrhage and trauma labs

›Resuscitation labs

›Complete blood count for bleeding concern

›Hemoglobin trend for ongoing hemorrhage

›Electrolytes and renal function

›Creatinine for contrast planning

›Coagulation studies for anticoagulant use or severe trauma

›INR

›aPTT

›Type and screen for anticipated operative management

›Massive transfusion pathway trigger if unstable

Infection and open fracture considerations

›Infection risk assessment labs

›Glucose for diabetes and wound risk

›Hyperglycemia association with infection risk

›Lactate for shock physiology

›Trend with resuscitation

›Pregnancy testing

›Serum beta hCG for reproductive potential

›Imaging and medication planning

06Diagnostic Tests/dt77

Scoring Systems

›Trauma decision frameworks

›Cervical spine clearance rules

›NEXUS criteria

›No midline cervical tenderness

›No intoxication

›Normal alertness

›No focal neurologic deficit

›No painful distracting injury

›Canadian C-spine rule high-risk features

›Age 65 years or older

›Dangerous mechanism

›Paresthesias in extremities

›Head injury CT decision tools when indicated

›Canadian CT Head Rule applicability

›Minor head injury population

›High-risk features prompting CT head

›GCS less than 15 at 2 hours

›Suspected open skull fracture

›Signs of basilar skull fracture

›Two or more vomiting episodes

›Age 65 years or older

›Facial fracture classifications for communication

›Le Fort I II III patterns

›Midface instability marker

›Naso-orbito-ethmoid classification

›Medial canthal tendon disruption concern

›Zygomaticomaxillary complex patterns

›Orbital involvement risk

›Mandibular anatomic sites

›Symphysis and parasymphysis

›Body

›Angle

›Ramus

›Condyle

›Coronoid

MRI

›MRI roles in facial trauma

›Soft tissue and nerve injury evaluation

›Traumatic optic neuropathy adjunct evaluation

›Indications

›Persistent neurologic deficits with nondiagnostic CT

›Suspected ligamentous cervical spine injury

›Contraindications and limitations

›Metallic foreign body concern

›Time and monitoring limitations in unstable patients

›CT as primary imaging modality

›CT maxillofacial without contrast

›Thin-cut acquisition

›Multiplanar reconstructions

›3D reconstructions for surgical planning

›CT head indications

›Altered mental status

›Loss of consciousness

›Anticoagulant use

›Signs of basilar skull fracture

›CT angiography indications in facial trauma

›Expanding neck hematoma

›Neurologic deficit suggesting vascular injury

›High-energy midface fractures with suspected arterial injury

›CT pearls by fracture type

›Orbital floor fracture

›Inferior rectus entrapment signs

›Large defect and herniation assessment

›Mandible fracture

›Condylar involvement evaluation

›Dental root involvement assessment

›Frontal sinus fracture

›Posterior table displacement assessment

›Outflow tract involvement assessment

Ultrasound

›Ultrasound adjuncts

›FAST or eFAST for polytrauma

›Free fluid screen

›Pneumothorax screen

›Ocular ultrasound constraints

›Avoid if globe rupture concern

›Consider for lens dislocation or vitreous hemorrhage only if safe and local protocol supports

›Airway ultrasound adjuncts

›Cricothyroid membrane localization in difficult anatomy

07Disposition/dispo35

Level of care and admission criteria

›ICU or step-down indications

›Airway risk

›Le Fort fractures with instability

›Floor of mouth hematoma

›Ongoing oropharyngeal bleeding

›Vision threat

›Orbital compartment syndrome

›Entrapment with bradycardia or severe nausea

›Intracranial injury

›CT head positive finding

›CSF leak concern

›Persistent clear rhinorrhea

›Operative or urgent specialty management indications

›Open mandibular fracture

›Gross contamination

›Malocclusion

›Frontal sinus posterior table fracture

›Significant displacement

›CSF leak

›Naso-orbito-ethmoid injury

›Medial canthal tendon disruption

Discharge criteria and follow-up

›Discharge appropriateness

›Isolated nondisplaced fracture

›Stable airway

›Controlled pain and nausea

›No vision compromise

›Normal visual acuity

›No concerning diplopia at rest

›No uncontrolled bleeding

›Epistaxis resolved

›Follow-up planning

›Maxillofacial surgery or ENT or plastic surgery within 3 to 7 days

›Earlier for significant displacement or malocclusion

›Ophthalmology within 24 to 72 hours for orbital fractures with symptoms

›Earlier for diplopia or motility deficit

08Treatment/t96

Airway and breathing

›Airway management principles

›Pre-oxygenation and suction

›Continuous suction during airway attempts

›Intubation approach selection

›Video laryngoscopy as first-line when feasible

›Surgical airway readiness

›Post-intubation considerations

›Secure tube with facial injury aware method

›Ventilation targets per associated injuries

Hemorrhage control and resuscitation

›Facial bleeding control

›Direct pressure and packing

›Hemostatic gauze option if available

›Epistaxis management

›Topical vasoconstrictor

›Anterior packing

›Posterior packing with airway protection

›Hemostatic resuscitation

›Balanced blood product strategy when massive transfusion triggered

›Tranexamic acid

›If major trauma with suspected significant bleeding then initiate

›1 g IV over 10 minutes

›Follow with 1 g IV over 8 hours

Ocular emergencies

›Orbital compartment syndrome management

›Immediate ophthalmology activation

›Vision decline trigger

›If high suspicion and delay expected then perform decompression

›Lateral canthotomy and cantholysis

›Document pre-procedure visual acuity if possible

›Globe injury precautions

›Rigid eye shield

›Avoid patch pressure

›Antiemetic therapy to prevent Valsalva

›Reduced IOP spikes

Fracture-specific management

›Nasal fractures

›Septal hematoma recognition

›Urgent drainage pathway with ENT

›External splinting considerations

›Follow-up for reduction timing

›Orbital floor fractures

›Entrapment and pediatric trapdoor concern

›Urgent surgical assessment if motility restriction with symptoms

›Sinus precautions

›Avoid nose blowing

›Decongestant considerations

›Short course if no contraindications

›Zygomaticomaxillary complex fractures

›Infraorbital nerve symptoms

›Sensory deficit documentation

›Trismus with arch involvement

›Urgent surgical assessment if severe

›Mandibular fractures

›Occlusion stabilization

›Soft diet

›Temporary immobilization options

›Barton bandage if appropriate

›Open fracture identification

›Intraoral mucosal laceration over fracture line

Antibiotics and tetanus

›Antibiotic strategy by fracture type

›Open mandibular fracture antibiotic coverage

›If not penicillin allergic then initiate

›Ampicillin-sulbactam 3 g IV every 6 hours

›Continue until operative fixation per local protocol

›If penicillin allergic then initiate

›Clindamycin 900 mg IV every 8 hours

›Continue until operative fixation per local protocol

›Oral transition when discharging on antibiotics per local protocol

›Amoxicillin-clavulanate 875 mg PO every 12 hours

›Typical duration per surgeon protocol

›Clindamycin 450 mg PO every 8 hours

›Typical duration per surgeon protocol

›Closed non-operative facial fractures

›No routine prophylactic antibiotics recommended by multiple guidelines

›Reassess if gross contamination or bite wound

›Basilar skull fracture with CSF leak

›No routine prophylactic antibiotics recommended in several guidelines

›Neurosurgery-directed management

›Tetanus prophylaxis

›If dirty wound and immunization incomplete then vaccinate and give immune globulin per protocol

›Document last tetanus date

Analgesia and antiemetics

›Analgesia ladder

›Acetaminophen

›1,000 mg PO every 6 hours as needed

›Maximum 4,000 mg per day

›Ibuprofen

›400 mg PO every 6 hours as needed

›Avoid in significant bleeding risk or renal failure

›Opioid for severe pain

›Morphine 0.05 mg/kg IV

›Repeat dosing based on response

›Hydromorphone 0.01 mg/kg IV

›Repeat dosing based on response

›Antiemetic options

›Ondansetron 4 mg IV or PO

›Repeat every 8 hours as needed

›Metoclopramide 10 mg IV

›Avoid in bowel obstruction

09Special Populations/sp24

Pregnancy

›Pregnancy considerations

›Imaging risk balance

›CT when clinically indicated

›Shielding and dose minimization principles

›Medication considerations

›Avoid teratogenic agents when alternatives exist

›Analgesia selection with obstetric awareness

›Rh status considerations with significant trauma

›Anti-D prophylaxis when indicated per obstetric guidance

Geriatric

›Older adult considerations

›Higher anticoagulant prevalence

›Low threshold for CT head and prolonged observation when indicated

›Osteoporosis and frailty

›Fractures with lower-energy mechanisms

›Delirium risk with opioids

›Multimodal analgesia preference

Pediatrics

›Pediatric considerations

›Trapdoor orbital fracture risk

›Minimal bruising with severe entrapment

›Nausea and bradycardia as key clues

›Weight-based dosing

›Medication dosing by kg

›Non-accidental trauma concern

›Safeguarding pathway activation when indicated

10Background/b27

Epidemiology

›Epidemiology overview

›Common mechanisms

›Assault and sports in younger populations

›Motor vehicle collisions in high-energy trauma

›Co-injury frequency

›Traumatic brain injury association in high-energy facial trauma

›High-risk fracture patterns

›Midface fractures with airway compromise risk

Pathophysiology

›Structural considerations

›Facial buttress system disruption

›Load transmission failure

›Orbital blowout mechanics

›Pressure transmission to thin orbital floor

›Mandibular fracture mechanics

›Tension compression forces across angle and parasymphysis

›Frontal sinus posterior table risk

›Barrier loss between sinus and intracranial space

Therapeutic Considerations

›Treatment principles

›Airway first in maxillofacial trauma

›Anatomy distortion and bleeding complicate intubation

›CT as imaging workhorse

›Thin-cut multiplanar utility for surgical planning

›Entrapment as time-sensitive condition

›Pediatric white-eyed blowout requiring urgent operative assessment

›Antibiotic stewardship

›Closed non-operative facial fractures without routine prophylaxis in guidelines

›Open mandibular fractures with anaerobic coverage preference in many protocols

11Patient Discharge Instructions/pdi26

copy discharge instructions

›Discharge instructions set

›Activity and protection

›Head elevation while resting

›Ice packs 15 minutes at a time for swelling

›Sinus precautions when orbital or midface fracture suspected

›No nose blowing

›Sneeze with mouth open

›Avoid heavy lifting and straining

›Diet

›Soft diet if jaw pain or suspected mandible injury

›Medications

›Acetaminophen as directed

›Ibuprofen as directed if safe

›Antibiotics only if prescribed

›Follow-up

›Maxillofacial surgery or ENT or plastic surgery appointment arranged

›Ophthalmology follow-up if orbital symptoms

›Return to ED immediately

›Vision change

›New double vision

›Increasing eye pain

›Severe headache with clear nasal drainage

›Uncontrolled bleeding

›Fever or worsening facial swelling

›Trouble breathing

›Inability to open mouth or worsening malocclusion

12References/r15

Clinical guidelines and key sources

›Evidence source set

›ATLS principles for maxillofacial trauma airway and resuscitation

›Airway and hemorrhage control prioritized before imaging

›ENT resident manual trauma to face head and neck

›CT as primary modality for facial fractures with thin cuts and multiplanar reconstructions

›AO Surgery Reference emergency treatment guidance for orbital fractures

›Emergent treatment usually reserved for visual compromise or retrobulbar hematoma

›Orbital floor fracture review literature

›Pediatric white-eyed blowout fracture as surgical emergency with early intervention

›Surgical Infection Society guidance on prophylactic antibiotics in traumatic facial fractures

›Avoid routine prophylaxis for non-operative facial fractures

›Institutional facial fracture antibiotic protocols

›Ampicillin-sulbactam and clindamycin options for open mandible fractures

›Frontal sinus fracture management references

›Posterior table and CSF leak as major drivers of operative strategy

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.