Treatment for Facial Fractures
The treatment of facial fractures requires a systematic approach prioritizing life-threatening conditions first, followed by surgical repair based on specific fracture timing guidelines to optimize functional and cosmetic outcomes. 1
Initial Assessment and Stabilization
Primary Survey (ABC's)
- Airway management: Facial fractures can compromise the airway through hemorrhage, soft-tissue edema, and loss of facial architecture 1
- Breathing assessment: Check for associated pulmonary injuries (present in 31.1% of severe facial trauma) 2
- Circulation: Evaluate for hemorrhagic shock (occurs in approximately 6.2% of facial fracture patients) 3
- Neurological status: Assess for traumatic brain injury (cerebral hematomas occur in 43.7% of facial trauma patients) 2
Secondary Survey
- Detailed facial examination: palpation, visual inspection, facial symmetry
- Ocular assessment: visual acuity, extraocular movements, pupillary response
- Cranial nerve evaluation
- Detection of cerebrospinal fluid leak
- Dental occlusion assessment 1
Diagnostic Imaging
CT maxillofacial: Gold standard for facial fracture evaluation
- Provides high-resolution images with thin-section acquisitions
- Allows multiplanar and 3D reconstructions for complex fracture characterization 1
CT head: Recommended for patients with suspected frontal sinus fractures due to high association with intracranial injuries (>33% of cases) 1
MRI: Reserved for specific cases requiring detailed soft tissue evaluation, not routine 1
Surgical Management Timeline
Immediate Repair (Emergency)
- Entrapped muscle/periorbital tissue with nonresolving oculocardiac reflex (bradycardia, heart block, dizziness, nausea, vomiting)
- White-eyed blow-out fracture with muscle entrapment (particularly in children)
- Globe subluxation into maxillary sinus 1
Early Repair (Within 2 Weeks)
- Symptomatic diplopia with positive forced ductions or entrapment on CT
- Large floor fractures with hypoglobus
- Progressive infraorbital hypoesthesia
- Early enophthalmos or hypoglobus causing facial asymmetry 1
Delayed Repair (After 2 Weeks)
- Restrictive strabismus
- Unresolved enophthalmos 1
Observation
- Minimal diplopia (not in primary or downgaze)
- Good ocular motility
- No significant enophthalmos or hypoglobus 1
Antibiotic Management
For facial fractures without evidence of infection:
- Non-operative fractures: Prophylactic antibiotics not recommended
- Operative non-mandibular fractures: Pre-operative antibiotics not recommended
- Operative mandibular fractures: Pre-operative antibiotics not recommended
- Post-operative antibiotics (>24 hours): Not recommended for any facial fracture type 4
Rehabilitation and Follow-up Care
- Early post-fracture physical training and muscle strengthening
- Long-term balance training and fall prevention
- Individualized rehabilitation plan based on patient goals and needs 1
Management of Persistent Strabismus After Fracture Repair
- Short burst of oral steroids to hasten recovery and identify persistent strabismus
- Conservative treatments: occlusion, filters, Fresnel prisms, prism glasses
- For persistent strabismus, wait 4-6 months after trauma before surgical correction unless substantial fat and orbital pulley entrapment suggests earlier repair 1
Complications to Monitor
- Approximately 15% of patients may experience postoperative functional problems
- About 13% may develop variable cosmetic deformities
- Approximately 17% may require subsequent reoperation 5
- Serious ocular injury occurs in 24% of blowout fracture cases 1
Special Considerations
- Mortality risk: Approximately 1.3% of severe facial trauma patients may die during hospitalization, primarily due to neurologic injuries 2
- Associated injuries: 11.3% of facial fracture patients sustain significant concomitant injuries outside the facial skeleton 6
Remember that the primary goal of facial fracture management is to restore both function and cosmesis while preventing complications that could impact morbidity, mortality, and quality of life.