A young man presents after being struck in the face with a baseball. His left eye is swollen shut, his nose is bleeding, and his cheek is flattened. The CT report shows multiple facial fractures, including an orbital floor fracture and a zygomaticomaxillary complex fracture. It is tempting to focus on the fracture pattern, but the most important initial questions are functional: Is the airway threatened? Is vision intact? Is there uncontrolled hemorrhage? Does the patient have malocclusion? Facial fractures are often better understood as markers of force transmission than as isolated injuries, because the same mechanism may also injure the brain, cervical spine, globe, optic nerve, carotid arteries, or airway. A systematic approach that prioritizes threatened function over fractures helps identify patients who need immediate intervention and avoids overreliance on CT findings.

Airway, Hemorrhage, and Vision Come First

The most time-sensitive complications of facial trauma are airway compromise, uncontrolled hemorrhage, and vision-threatening ocular injury. In maxillofacial trauma, airway compromise is usually caused not by the fracture itself but by hemorrhage, soft-tissue edema, disruption of facial architecture, loose teeth, bone fragments, or associated upper airway injury. Airway deterioration may also be delayed as swelling progresses, so repeated reassessment is as important as the initial examination.^1,2,3 Progressive edema and hemorrhage can convert a straightforward airway into a difficult airway within minutes to hours.

A bilateral parasymphyseal mandibular fracture deserves special attention because loss of anterior mandibular support can contribute to posterior tongue displacement and airway obstruction, particularly after sedation or loss of muscle tone.^3,4 This is why the bilateral parasymphyseal mandibular fracture is the classic facial fracture associated with airway obstruction. If posterior tongue displacement is present and the airway is threatened, temporary tongue traction with a towel clip or suture through the tongue attached to a weight to bring the tongue anterior may prevent complete airway collapse.

Severe facial hemorrhage is uncommon but can be difficult to control. Initial management follows standard trauma principles, including airway protection, resuscitation, direct pressure, packing, and escalation when bleeding persists. In refractory cases, angiographic embolization is often more effective than operative ligation.^3,7 At the bedside in the emergency department (ED), when facial bleeding after midface fracture is difficult to control, consider reducing the displaced maxillary fracture to provide hemostasis, similar to reduction of a femur fracture for the same purpose.

The Physical Examination Matters More Than the CT Scan

Modern CT detects facial fractures with high sensitivity, but fracture presence alone rarely determines urgency. Management is driven by threatened function on bedside examination.^4-6 Visual acuity, pupillary examination, extraocular movements, globe position, malocclusion, cranial nerve deficits, hearing loss, and septal hematoma are clinically determined findings that often matter more acutely than the fracture pattern itself.^4-6

Several examination findings deserve particular emphasis. Subjective malocclusion is a high-yield clue to mandibular injury, and lower lip numbness supports involvement of the inferior alveolar nerve in mandibular fractures.^3,4 Septal hematoma requires prompt recognition because delayed treatment risks cartilage necrosis and saddle-nose deformity. A useful practical rule is this: CT identifies fractures; the physical examination identifies threatened function.^3-5

Stop Memorizing Le Fort Fractures

Although the Le Fort classification remains useful for surgical description, it is often less practical during the initial ED evaluation than thinking in terms of functional facial regions.⁵ The upper face, including the frontal bone, frontal sinus, and superior orbital rims, raises concern for associated intracranial injury, cervical spine injury, and cerebrospinal fluid leak.^3,5,6 The midface, including the orbits, zygomas, maxilla, and naso-orbito-ethmoid (NOE) region, threatens vision, globe position, facial width, parotid injury, and structural support.^3,5 The lower face, including the mandible and dentoalveolar structures, is most relevant to airway patency, mastication, occlusion, and inferior alveolar nerve injury.^3,4 Think of the upper face as protecting the brain and frontal sinus, the midface as protecting vision and facial support, and the mandible as protecting airway and dental occlusion.

Frontal Sinus Fractures Predict More Than They Cause

Frontal sinus fractures generally reflect substantial force and should prompt concern for associated injury rather than focus solely on the anterior table fracture itself. Evaluation should emphasize posterior involvement, possible cerebrospinal fluid communication, and associated intracranial injury.^3,5,6 Clear rhinorrhea when the patient bends forward or postnasal drainage in the supine patient after trauma should increase suspicion for cerebrospinal fluid leak, and posterior table fractures warrant urgent specialist involvement.^5,6

Orbital Fractures: Focus on the Eye, Not the Bone

Orbital fractures are common, but the emergency is usually the eye rather than the bone. Assessment should prioritize visual acuity; pupillary examination, including a relative afferent pupillary defect; extraocular movements; diplopia; globe position; and intraocular pressure when appropriate.^2,3,5 Globe malposition and infraorbital sensory deficits may further support orbital floor injury.^3,5

A key clinical pearl is to assess globe position from below while the patient looks upward. Subtle asymmetry is often easier to appreciate from this perspective than from a standard frontal view.

The vision-threatening diagnosis that cannot be missed is orbital compartment syndrome. Retrobulbar hemorrhage can rapidly compromise optic nerve and retinal perfusion, and permanent visual loss may occur within a short time window.^2,8,9 Decreased visual acuity, proptosis, ophthalmoplegia, elevated intraocular pressure, or a relative afferent pupillary defect should prompt immediate lateral canthotomy and cantholysis without waiting for CT imaging or consultant arrival.^2,8,9 Imaging may help define associated injury in stable patients, but it is complementary and not required before decompression when orbital compartment syndrome is strongly suspected.² One common clinical pitfall is waiting for CT imaging before performing a lateral canthotomy in a patient with clear clinical evidence of orbital compartment syndrome. One seeming contradiction is that highly displaced orbital fractures often appear alarming on CT but are actually less likely to trap extraocular muscles than less displaced fractures.¹⁰

Not Every Nasal Fracture Needs a CT Scan

Nasal fractures are the most common facial fractures and are frequently overimaged. Radiographs have limited value, and management of uncomplicated nasal trauma is often determined clinically rather than radiographically.⁴ The key distinction is not simply whether the nose is fractured, but whether the injury appears isolated or is part of a more complex midfacial injury. Associated telecanthus, orbital findings, malocclusion, significant midface tenderness, or broader deformity should raise suspicion for additional fractures.^3-5

Palpation tenderness or instability of the anterior nasal spine at the base of the columella should raise suspicion for a more significant central facial injury rather than an isolated nasal fracture.

Every patient with nasal trauma should undergo intranasal examination for septal hematoma. Because the morbidity of a missed septal hematoma is substantial, uncertainty should lower the threshold for prompt definitive evaluation and treatment. A septal hematoma is boggy and fluctuant, whereas traumatic edema is typically firm and diffuse. If the finding is equivocal, have a low threshold to aspirate or incise a suspicious lesion—missing a septal hematoma risks cartilage necrosis and permanent saddle-nose deformity, and a negative aspiration causes minimal harm.

Don’t Miss the NOE Fracture

NOE fractures are easy to miss early because swelling can obscure the diagnosis. These injuries matter because they threaten globe position, medial canthal support, nasal projection, sinus drainage, and facial symmetry. These aspects should guide your evaluation.⁵ Traumatic telecanthus is the hallmark finding. Flattening of the nasal bridge, severe periorbital ecchymosis, central midface tenderness, orbital injury, and instability should all heighten suspicion.⁵

Observe the Patient’s Bite

Mandibular fractures are among the most clinically important facial fractures because they affect occlusion, mastication, and sometimes airway patency.^3,4 A patient’s report that the bite feels abnormal is an important diagnostic clue and should be taken seriously.^3,4 Examination should assess for malocclusion, trismus, gingival injury or bleeding, loose teeth, lower lip sensation, crepitus, and step-off deformities.^3,4 Because the mandible functions as a ring, a second fracture site is common and should be actively sought.⁴ Gentle compression of both mandibular angles that causes pain at a different site in the mandible is highly suggestive of a mandibular fracture.¹¹

Conversely, the tongue blade test has high sensitivity for mandibular fracture. A wooden tongue depressor is placed between the patient’s upper and lower molars on one side of the mouth. The patient is then instructed to bite down firmly. The examiner then attempts to twist or pull the tongue blade until it breaks or slips out. The test is repeated between the contralateral molars. If the patient can break the tongue blade or it cannot be pulled out, the test has greater than 95 percent sensitivity and is an effective tool for ruling out a mandibular fracture.¹²

Any mandibular fracture that communicates with the tooth-bearing oral cavity is considered an open fracture, and antibiotic prophylaxis is commonly recommended.^13,14 Routine prophylactic antibiotics are generally not recommended for closed, nondisplaced, or nonoperative mandibular fractures that do not communicate with open skin wounds or the oral cavity.^{13, 14}

So, the next time you are faced with a patient with facial trauma, remember that facial trauma is memorable because of how dramatic it looks, but successful emergency management depends on looking beyond the fracture itself. Prioritize airway, vision, and hemorrhage. Perform a careful functional examination. Think in facial regions rather than memorized fracture diagrams. It is important to understand that CT identifies broken bones, but the bedside examination identifies threatened function.

A special thanks to Dr. Jeff Fialkov and Dr. Andrew Petrosoniak for their contributions to the EM Cases podcast that inspired this article.

Dr. Helman is an emergency physician at North York General Hospital in Toronto. He is an assistant professor in the division of emergency medicine at the University of Toronto, and the education innovation lead at the Schwartz/Reisman Emergency Medicine Institute. He is the founder and host of the Emergency Medicine Cases podcast and website.

References

1. Mercer SJ, Jones CP, Bridge M, et al. Systematic review of the anaesthetic management of non-iatrogenic acute adult airway trauma. Br J Anaesth. 2016; 117 (Supplement 1): I49-I59. Available at: https://www.bjanaesthesia.org.uk/article/S0007-0912(17)33768-6/fulltext.
2. Coccolini F, Improta M, Cicuttin E, et al. Timing of surgical intervention for compartment syndrome in different body region: systematic review of the literature. World J Emerg Surg. 2020;15(1):60. doi: 10.1186/s13017-020-00339-8.
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