How do I diagnose a facial bone fracture?

Diagnosing Facial Bone Fractures

CT imaging is the gold standard for diagnosing facial bone fractures, providing high-resolution multiplanar and 3D reconstructions that accurately identify fracture patterns, displacement, and associated injuries. 1, 2

Clinical Assessment

Before imaging, assess for:

• Point tenderness over facial bones
• Facial asymmetry or deformity
• Mobility or crepitus of facial bones
• Malocclusion (for maxillary/mandibular fractures)
• Infraorbital nerve paresthesia (suggests zygomatic/maxillary fracture)
• Periorbital ecchymosis ("raccoon eyes")
• Septal hematoma (requires immediate evacuation)
• Nasal airway patency
• Facial elongation (suggests Le Fort fractures)

Imaging Protocol

First-Line Imaging:

• Maxillofacial CT with thin sections (1-2mm slices)
  • Provides superior visualization of bony architecture
  • Allows for multiplanar reconstruction
  • Detects 95% of facial fractures 1
  • Essential for surgical planning

Specific CT Protocols:

1. For midface injuries: Maxillofacial CT is superior to head CT for evaluating zygoma, maxilla, and orbital fractures 1
2. For temporal bone/facial nerve involvement: High-resolution temporal bone CT with thin sections 1
3. For frontal bone injuries: CT head or maxillofacial CT 1

Alternative Imaging Options:

• Ultrasound: Excellent radiation-free alternative for isolated nasal fractures (90-100% sensitivity, 98-100% specificity) 2
• Plain radiographs: Limited diagnostic value (53-82% accuracy) and generally not recommended 2

Common Fracture Patterns to Identify

1. Nasal fractures (most common - 37.7% of isolated fractures) 3

   • Often involve the septum (96.2% of cases) 4
   • Evaluate for septal hematoma or deviation

2. Mandibular fractures (30% of isolated fractures) 3

   • Check for malocclusion and mobility

3. Orbital fractures (7.6% of isolated fractures) 3

   • Evaluate for enophthalmos and diplopia

4. Zygomatic fractures (5.7% of isolated fractures) 3

   • Look for flattening of cheek and infraorbital nerve paresthesia

5. Le Fort fractures (complex maxillary fractures) 1

   • All involve pterygoid plates
   • Le Fort I: horizontal fracture of maxilla
   • Le Fort II: pyramidal fracture involving maxilla and nasal bones
   • Le Fort III: complete craniofacial separation

Pitfalls to Avoid

1. Missing associated injuries:

   • 68% of facial fracture patients have associated head injuries 1
   • Consider concurrent head CT when facial fractures are identified

2. Overlooking septal fractures:

   • Present in 96.2% of nasal bone fractures 4
   • CT may not accurately predict severity of septal fractures

3. Failing to identify septal hematoma:

   • Requires immediate evacuation to prevent cartilage necrosis 2

4. Underestimating complex fracture patterns:

   • Isolated fractures may be part of more extensive facial trauma

5. Relying solely on plain radiographs:

   • Significantly lower accuracy compared to CT 2, 5

By following this systematic approach to diagnosing facial bone fractures, you can ensure accurate identification of fracture patterns and guide appropriate management decisions.