Facial Fractures

History clarifies mechanism and flags must-not-miss associations: loss of consciousness, post-traumatic seizure, focal neurology, escalating headache, post-traumatic amnesia, and cervical spine pain. NICE NG232 and NG41 triage applies. In sport, screen for concussion; if suspected, remove from play and follow the graduated return pathway independently of facial fracture recovery.

Examination:

• •Inspect for asymmetry, swelling, bony step, saddle nasal deformity, septal haematoma (smooth fluctuant blue-purple swelling on the septum), periorbital ecchymosis, subconjunctival haemorrhage extending posteriorly, enophthalmos or proptosis, and trismus
• •Palpate bony rims: supraorbital, infraorbital, zygomatic arch, mandibular condyle, body, angle, and symphysis
• •Test CN V (infraorbital nerve numbness over the cheek and upper lip is the cardinal sign of zygomatic complex or orbital floor fracture)
• •Test CN III/IV/VI extraocular movements - restricted upgaze suggests orbital floor entrapment with diplopia
• •Assess dental occlusion - a step in occlusion is a sensitive sign of mandibular or maxillary fracture
• •Tongue blade test: ask the patient to bite firmly on a wooden depressor while you twist it; pain causes the patient to open before the blade breaks (~95 percent negative predictive value for mandibular fracture)

Check for CSF rhinorrhoea (the halo or double-ring sign is non-specific; beta-2 transferrin is confirmatory). Advise any patient with suspected orbital fracture not to blow the nose to avoid orbital surgical emphysema. Consider safeguarding in children and vulnerable adults where the mechanism is inconsistent.

Isolated adult nasal bone fracture without septal haematoma needs no routine imaging. The diagnosis is clinical and management is based on cosmesis and septal assessment.

For all other suspected facial fractures, CT facial bones is the investigation of choice - identifying fracture pattern, displacement, comminution, and associated soft tissue concerns. Plain skull and facial radiographs have largely been superseded. For suspected mandibular fracture, CT is preferred in high-energy or panfacial trauma; OPG plus PA mandible may still be used in selected isolated mandibular injuries per local OMFS pathway.

For adults aged 16+, NICE NG232 indicates CT head within 1 hour for GCS 12 or less, GCS under 15 at 2 hours, suspected open or depressed skull fracture, basal skull fracture signs (including CSF leak), post-traumatic seizure, focal neurological deficit, or more than one episode of vomiting. Children follow the paediatric pathway with different thresholds and explicit NAI risk factors. Cervical spine imaging follows NICE NG41. MRI has a niche role for optic nerve and globe injury assessment.

Pre-hospital and immediate priorities follow standard trauma principles (ABCDE with cervical spine protection). Mandibular fractures, especially bilateral or flail patterns, threaten the airway; sit the patient forward (if cervical spine cleared), use jaw thrust, and control bleeding. In Le Fort fractures with airway compromise, a gloved hand drawing the unstable midface segment forward can temporarily re-establish the airway while preparing for advanced airway management.

Pattern-specific management:

• •Nasal fracture: exclude septal haematoma on the day of presentation. Septal haematoma = same-day ENT or OMFS drainage. If deformity persists, arrange ENT/maxillofacial review after swelling settles (4 to 7 days), with closed manipulation usually around 7 to 14 days in adults
• •Zygomatic complex with displacement, trismus, infraorbital symptoms, or cosmetic deformity: OMFS referral for ORIF
• •Orbital floor in adults: urgent referral for restricted eye movements, persistent diplopia, enophthalmos, large defect, reduced vision, globe injury concern, infraorbital nerve symptoms, or oculocardiac features
• •Paediatric trapdoor (white-eyed) blow-out with entrapment, vomiting, or bradycardia: same-day surgical emergency
• •Maxillary (Le Fort) fractures: all need OMFS referral and ORIF
• •Mandibular fractures: OMFS referral; non-displaced ramus or condyle fractures may be managed conservatively with soft diet, but most require ORIF or intermaxillary fixation
• •CSF leak: suggests basal skull fracture - neurosurgical or ENT input per NICE NG232

Orbital compartment syndrome from retrobulbar haemorrhage (severe pain, proptosis, tense globe, high IOP, reduced acuity or colour vision, RAPD) requires immediate lateral canthotomy and cantholysis without waiting for CT or ophthalmology. The key contraindication is suspected open globe injury.

Antibiotics: clearly considered for open or contaminated fractures, bite wounds, through-and-through oral wounds, mandibular fractures communicating with the oral cavity, and peri-operative prophylaxis - co-amoxiclav is the standard UK agent. Do not give automatically for closed midface or orbital fractures. Tetanus assessment is mandatory for any open injury. Analgesia: paracetamol and NSAIDs per BNF. Most facial fractures beyond a simple isolated nasal fracture warrant same-day or next-day OMFS review.

Rehabilitation depends on pattern. After conservative nasal fracture care: swelling control, avoid contact sport, review at 4 to 7 days for closed manipulation if needed. Chronic septal injury with obstruction may need delayed septorhinoplasty.

After ORIF for zygomatic, orbital, maxillary, or mandibular fracture: soft diet for 4 to 6 weeks, oral hygiene, jaw range exercises (especially after mandibular fracture), and graduated return to function. Trismus is the dominant post-mandibular complication and benefits from supervised mobility work.

Sport return is criteria-based: pain-free function, normal occlusion, normal range, and a custom-fitted protective face guard. Stable nasal patterns typically 4 to 6 weeks; stable zygomatic, orbital, or mandibular patterns after fixation 6 to 8 weeks; complex Le Fort or comminuted injuries longer. Concomitant concussion clearance is independent and must precede return to play. Psychological support and disfigurement counselling are under-recognised needs after significant facial injury.

• •NICE NG232 (Head injury) - CT head thresholds and paediatric NAI risk factors.
• •NICE NG41 (Spinal injury) - Canadian C-spine rule-based imaging triage.
• •BAOMS - UK specialty consensus for fracture management, surgical approaches, and timing.
• •ENT UK Global Nasal Trauma Guideline - septal haematoma drainage timing, closed manipulation window.
• •AO CMF Foundation - international reference for facial fracture classification and operative technique.

• •Le Fort I/II/III all involve the pterygoid plates; III is craniofacial dissociation with airway risk.
• •Paediatric white-eyed trapdoor is a same-day surgical emergency (oculocardiac reflex).
• •Septal haematoma drains same-day to prevent saddle nose.
• •Infraorbital nerve numbness is the cardinal sign of zygomatic complex or orbital floor fracture.
• •Tongue blade test has ~95 percent negative predictive value for mandibular fracture.
• •CT facial bones is imaging of choice except for isolated nasal fracture; teardrop sign = orbital floor blow-out.