What is the appropriate emergency assessment and management plan for a patient with a facial fracture?

Emergency Assessment and Management of Facial Fractures

Prioritize airway, breathing, and circulation stabilization immediately, followed by systematic CT maxillofacial imaging without contrast once the patient is hemodynamically stable, with mandatory neurosurgery and ophthalmology consultation based on fracture pattern and associated injuries. 1

Primary Survey: Life-Threatening Priorities

Airway management takes absolute precedence before any facial assessment, as maxillofacial trauma causes airway compromise through hemorrhage, soft-tissue edema, and loss of facial architecture. 1 In severe cases requiring intubation, maintain systolic blood pressure > 110 mmHg and control ventilation with end-tidal CO2 monitoring to prevent secondary brain injury. 2

Critical Associated Injuries Requiring Immediate Identification

• Cerebral trauma is present in 68% of facial fracture patients and represents the most common life-threatening injury requiring craniotomy. 1, 3
• Hemorrhagic shock occurs in approximately 2% of cases and demands immediate resuscitation with vasopressors (phenylephrine or norepinephrine) if hypotension develops. 2, 3
• Cervical spine injury occurs in 11% of mandibular fractures and 7-19% of significant maxillofacial trauma—cervical spine clearance is mandatory before any facial manipulation. 1
• Airway compromise requiring intervention occurs in approximately 2% of cases. 3

Secondary Survey: Systematic Facial Assessment

Once life-threatening injuries are managed, perform a comprehensive facial evaluation including:

• Palpation of all facial bones for step-offs and crepitus 1
• Visual inspection for asymmetry, deformity, and lacerations 1
• Functional testing: full visual acuity, extraocular movements, cranial nerve evaluation 1
• Specific midface indicators: pain with upper jaw manipulation, infraorbital nerve paresthesia, facial elongation, malocclusion—all suggest zygomaticomaxillary complex or Le Fort fractures 1
• CSF leak detection and dental occlusion assessment 1

Diagnostic Imaging Algorithm

CT maxillofacial without contrast is the definitive first-line imaging modality, providing superior delineation of osseous and soft-tissue structures with high resolution that detects subtle nondisplaced fractures. 1, 4 Multiplanar and 3D reconstructions significantly improve surgical planning and surgeon confidence. 4

Add CT head without contrast when intracranial injury is suspected, given the 68% incidence of concomitant cerebral injury. 1

Special Vascular Imaging Considerations

Perform CT-angiography of supra-aortic and intracranial arteries when these high-risk features are present: 2

• Le Fort II or III facial fractures
• Basal skull fractures
• Cervical spine fractures
• Focal neurological deficits unexplained by brain imaging
• Horner syndrome
• Soft tissue neck lesions

Mandatory Specialty Consultations

Neurosurgery consultation is required for all patients with intracranial injury (68% of facial fracture patients) and specifically for orbital wall fractures, as 9% have concomitant intracranial injury. 1

Ophthalmology consultation is mandatory for all orbital fractures to assess visual acuity, extraocular movements, and globe integrity. 1

Initial Treatment Measures

For acute maxillary fractures, implement: 1

• Elevation of head of bed
• Sinus precautions
• Antibiotic prophylaxis

Coordinated pain management is essential for multiple painful injuries that characterize polytrauma. 5

Critical Pitfalls to Avoid

• Never manipulate the face before cervical spine clearance—11% of mandibular fracture patients have concomitant cervical spine injury. 1
• Do not miss hemorrhagic shock—two of five mortalities in one large series resulted from hemorrhagic shock not identified until long after admission. 3
• Avoid hypotension below 110 mmHg systolic—mortality markedly increases with systolic blood pressure < 110 mmHg in patients with associated traumatic brain injury. 2
• Do not delay imaging—CT must be performed without delay in cases of coma or abnormal neurological examination. 2

Definitive Management Timing

All fractures should be repaired within 10 days after injury using open reduction and internal fixation with titanium plates and screws through standard surgical approaches, which results in good to excellent outcomes with a 16.7% reoperation rate. 6