Facial Injuries

NB Facial x-rays must be of good quality and should be taken PA and not AP. If the patient's clinical condition does not allow this (e.g. they are intoxicated or have other injuries) and the patient is being admitted with other injuries (eg head injury) it may be better to wait and get proper x-rays the following morning. 
Suspected Fractures of the Mandible
Beware airway problems in patient with bilateral mandible fractures. Ask patient if bite feels abnormal (highly significant). Test bite strength by asking to bite on a tongue depressor. Remember to look for intra-oral swelling or lacerations and lower lip or gum anaesthesia (inferior alveolar nerve). Obtain OPG AND PA jaw. TMJ views are seldom helpful. 
Suspected Fractures of Zygoma, Orbital Floor and Orbital Rim.
Symptoms and signs may include: Black eye, visible depression of cheek, infra-orbital anaesthesia, surgical emphysema of face, tenderness of the frontal-zygomatic suture, lateral subconjuctival haemorrhage with no posterior limit and radiological signs of blood in the antrum.   These fractures may not be visible on a standard facial x-ray.  Therefore, all patients with good clinical evidence of a fracture but with normal x-rays should be referred to the Maxillofacial team for review.
Dislocated Temporo-mandibular Joint
This is a clinical diagnosis and does not need x-rays.  It can usually be reduced by manipulation. Sedation may be useful. Seek senior ED advice. Following reduction refer to Maxillofacial team for follow up. 
Le Fort Fractures of the Middle Third of the Face
Marked swelling is likely. Look for CSF rhinorrhea.  
Grasp the upper alveolus and attempt to pull / push -if it moves, then there is a middle third fracture but absence of movement does not exclude fracture.
These are serious injuries with a risk of airway problems.  
All facial fractures should be discussed with the Maxillofacial team. 
Fractured Nose
This is a clinical diagnosis and there is no indication for X-ray. Look for septal haematoma (an emergency – refer to ENT).  
- Undisplaced fractures require no treatment
- Displaced fractures: arrange next available ENT clinic. NB fractured nose is a rare injury in children 
Soft Tissue Injury
Remember the risk to superficial structures – e.g. facial nerve  
Approximate tissues exactly, especially at the vermillion and nasal margins. Ear lacerations - do not suture auricular cartilage but close the overlying skin. If extensive laceration, consider packing external auditory meatus with gelonet.