Facial fractures

Last updated: July 6, 2023

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Summarytoggle arrow icon

Facial fractures include fractures of the forehead, orbits, midface, and mandible. They are typically caused by high-energy blunt trauma related to sports, violent altercations, motor vehicle collisions, or falls. Facial fractures may be simple, involving a single bone (e.g., nasal bone fracture, zygomatic arch fractures), or complex, involving more than one bone (e.g., Le Fort fractures, zygomaticomaxillary complex fractures). Facial fractures can be further classified based on the number of fracture lines (simple or comminuted fractures), displacement, and soft tissue involvement (open fractures or closed fractures). Clinical features vary depending on the bones involved but usually include facial pain, bruising, palpable step-off, and mobile bone fragments. Initial management of facial fractures focuses on identifying and addressing life-threatening injuries. Complications of facial fractures include nasal and/or oropharyngeal bleeding, traumatic eye injury, cranial nerve deficits, traumatic brain injury (TBI), CSF leakage, sinus wall breach, dental injury, and facial disfiguration. Expectant management may be sufficient for simple fractures but surgery may be necessary for unstable fractures and fractures with associated complications.

For details on forehead and frontal bone fractures, see “Skull fractures.”

For details on orbital fractures, see “Traumatic eye injuries.”

Overviewtoggle arrow icon

Midfacial fractures

Overview of facial fractures
Common subtypes Affected structures
Complex midfacial maxillary fractures
Nasal fractures
Zygomatic fractures

Other facial fractures

Managementtoggle arrow icon

Initial approach [2][3]

Follow the advanced trauma life support (ATLS) algorithm and prioritize immediate stabilization of life-threatening injuries.

Red flags for a difficult airway in patients with facial fractures include oropharyngeal bleeding, expanding hematomas, and/or significant distortion of the mouth, oropharynx, and/or upper neck. [2]

Supportive care [2]

Prophylactic antibiotics for facial injuries [2][4]

Prophylactic antibiotics are not routinely recommended. Follow local protocols and specialist advice. [2][4]

Definitive management [2][6][7]

The following principles apply generally to facial fractures. For fracture-specific management: See “Nasal fractures,” “Zygomatic fractures,” and “Mandibular fracture.”

Disposition [2]

Diagnosticstoggle arrow icon

Clinical evaluation [2][3]

Imaging [2][3]

Facial fractures are often caused by high-energy impacts. Maintain a low threshold for imaging the head and cervical spine to assess for associated injuries. [2]

Laboratory studies [2][3]

Midfacial fracturestoggle arrow icon



Etiology [6][9]

High-energy impact to the midface, e.g., due to:

Clinical features

See also “Clinical features” in “Nasal bone fractures” and “Zygomatic bone fractures.”

  • Facial contusions, local swelling, and tenderness
  • Facial asymmetry and midface instability of varying degree
  • Palpable gap along the surface of the bone
  • Subcutaneous emphysema in paranasal sinus fractures [10]

Complex midfacial maxillary fractures

The Le Fort classification is used to guide the management of complex midfacial fractures. Simple midfacial fractures (e.g., limited to the nasal, orbital, and/or ethmoid bones) are not captured in this system. [6]

Le Fort classification system [9][11]


Type of maxillary fracture

Affected bony structures

Distinguishing features

Le Fort I
  • Horizontal fracture due to downward impact against the alveolar ridge.
Le Fort II
Le Fort III
  • Transverse fracture due to impact against the upper maxilla and nasal bridge.

Midfacial fractures can cause significant blood loss and/or airway compromise because of the rich blood supply and swelling potential of involved structures. [12]

Nasal bone fracturetoggle arrow icon

Epidemiology [13]

Etiology [14]

  • Motor vehicle crashes
  • Physical violence (e.g., punches, elbowing)
  • Sports-related injuries (e.g., soccer, basketball)

Clinical features [15]

See also “Classification” and “Clinical features” in “Midfacial fractures” for complex facial fractures involving the nasal bones.

The inability to breathe through one or both nares indicates nasal airway obstruction. [2]

Diagnostics [13][15]

See also “Diagnosis of facial fractures.”

Some abnormalities may not be immediately apparent. Patients with uncomplicated isolated nasal injury should be reevaluated 3–5 days after the injury once the swelling has subsided. [2]

Treatment [13][15]

Initial management

See also “Approach to management of facial fractures” for patients with nonisolated nasal injury or multiple trauma.

Obtain urgent specialist consult for patients with nasal septal hematoma, CSF rhinorrhea, and/or abnormal extraocular movement examination.

Definitive treatment

Patients with isolated nasal injury, no septal hematoma or nasal airway obstruction, and controlled epistaxis may be discharged with close otolaryngology or plastic surgery follow-up after 3–5 days.


Nasal septal hematoma [13][15]

  • Definition: a collection of blood around the nasal septal bone or cartilage with intact nasal mucosa
  • Etiology: nasal or facial trauma
  • Clinical features
    • Unilateral or bilateral obstruction of the nasal lumen with blood-filled mucosa
    • Absence of overt bleeding (due to intact nasal mucosa)
  • Diagnostics: rhinoscopy showing unilateral or bilateral balloon-like bloody protrusion
  • Treatment: immediate surgical drainage
  • Complications
    • Infection
    • Septal perforation
    • Nasal deformities

Undiagnosed or improperly managed nasal septal hematomas may have severe consequences, such as infection, nasal septal perforation, and saddle nose deformity.


Zygomatic bone fracturetoggle arrow icon

Definitions [6]



  • Sports-related injuries (e.g., direct impact with sporting equipment or players)
  • Physical altercations (e.g., punch or elbow impact with the malar eminence)

Clinical features [6][17]

See also “Le Fort classification” for complex facial fractures involving the zygomatic bone.

Diagnostics [6][17]

See also “Diagnosis of facial fractures.”

Treatment [6][17]

See “Facial fracture management” for a general approach.

Conservative management

  • Indications: nondisplaced or minimally displaced stable fractures
  • interventions
    • Analgesia
    • Physical measures (cooling, decongesting nose drops) and functional relief (e.g., soft food)
    • Closed reduction of minimally displaced, uncomplicated fractures
    • Observation

Operative management

Consult maxillofacial surgery for all ZMC fractures and Le Fort fractures.

Mandibular fracturetoggle arrow icon

Etiology [2][7]

Clinical features [2][7]

Ecchymosis of the floor of the mouth is pathognomonic for mandibular fractures. [7]

Diagnostics [2][7]

See also “Diagnosis of facial fractures.”

Maintain a low threshold for imaging the head and cervical spine to assess for associated injuries in patients with a mandibular fracture. [2][7]

Treatment [2][7][20]

See “Management of facial fractures” for the initial approach.

Consult maxillofacial surgery for all mandibular fractures.

Monitor patients with bilateral mandibular fractures for airway compromise.

Referencestoggle arrow icon

  1. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  2. Truong T. Initial Assessment and Evaluation of Traumatic Facial Injuries. Semin Plast Surg. 2017; 31 (02): p.069-072.doi: 10.1055/s-0037-1601370 . | Open in Read by QxMD
  3. Forrester JD, Wolff CJ, Choi J, Colling KP, Huston JM. Surgical Infection Society Guidelines for Antibiotic Use in Patients with Traumatic Facial Fractures. Surg Infect (Larchmt). 2021; 22 (3): p.274-282.doi: 10.1089/sur.2020.107 . | Open in Read by QxMD
  4. Mundinger GS, Borsuk DE, Okhah Z, et al. Antibiotics and Facial Fractures: Evidence-Based Recommendations Compared with Experience-Based Practice. Craniomaxillofacial Trauma & Reconstruction. 2015; 8 (1): p.64-78.doi: 10.1055/s-0034-1378187 . | Open in Read by QxMD
  5. Louis M, Agrawal N, Kaufman M, Truong T. Midface Fractures I. Seminars in Plastic Surgery. 2017; 31 (02): p.085-093.doi: 10.1055/s-0037-1601372 . | Open in Read by QxMD
  6. Serebrakian A, Maricevich R, Pickrell B. Mandible Fractures. Semin Plast Surg. 2017; 31 (02): p.100-107.doi: 10.1055/s-0037-1601374 . | Open in Read by QxMD
  7. Hwang K. Analysis of facial bone fractures: An 11-year study of 2,094 patients. Indian Journal of Plastic Surgery. 2010.
  8. Phillips BJ, Turco LM. Le Fort Fractures: A Collective Review.. Bulletin of emergency and trauma. 2017; 5 (4): p.221-230.doi: 10.18869/acadpub.beat.5.4.499. . | Open in Read by QxMD
  9. Brasileiro BF, Cortez ALV, Asprino L, et al. Traumatic Subcutaneous Emphysema of the Face Associated With Paranasal Sinus Fractures: A Prospective Study. Journal of Oral and Maxillofacial Surgery. 2005; 63 (8): p.1080-1087.doi: 10.1016/j.joms.2005.04.007 . | Open in Read by QxMD
  10. Patel BC;. Le Fort Fractures. StatPearls. 2021.
  11. Nastri AL, Gurney B. Current concepts in midface fracture management. Curr Opin Otolaryngol Head Neck Surg. 2016; 24 (4): p.368-375.doi: 10.1097/moo.0000000000000267 . | Open in Read by QxMD
  12. Louis M et al. Midface fractures I. Seminars in plastic surgery. 2017.
  13. Goodmaker C, De Jesus O. Nasal Fracture. StatPearls. 2021.
  14. Kucik CJ, et al. Management of acute nasal fractures. American Family Physician. 2004.
  15. Strong EB, Gary C. Management of Zygomaticomaxillary Complex Fractures. Facial Plast Surg Clin North Am. 2017; 25 (4): p.547-562.doi: 10.1016/j.fsc.2017.06.006 . | Open in Read by QxMD
  16. Boswell KA. Management of Facial Fractures. Emerg Med Clin North Am. 2013; 31 (2): p.539-551.doi: 10.1016/j.emc.2013.01.001 . | Open in Read by QxMD
  17. Neiner J, Free R, Caldito G, Moore-Medlin T, Nathan CA. Tongue Blade Bite Test Predicts Mandible Fractures. Craniomaxillofac Trauma Reconstr. 2016; 9 (2): p.121-124.doi: 10.1055/s-0035-1567812 . | Open in Read by QxMD
  18. Nardi C, Vignoli C, Pietragalla M, et al. Imaging of mandibular fractures: a pictorial review. Insights into Imaging. 2020; 11 (1).doi: 10.1186/s13244-020-0837-0 . | Open in Read by QxMD
  19. Pickrell BB, Hollier LH. Evidence-Based Medicine. Plast Reconstr Surg. 2017; 140 (1): p.192e-200e.doi: 10.1097/prs.0000000000003469 . | Open in Read by QxMD
  20. Papadiochos I, Goutzanis L, Petsinis V. Flail Mandible and Immediate Airway Management. J Craniofac Surg. 2017; 28 (5): p.1311-1314.doi: 10.1097/scs.0000000000003706 . | Open in Read by QxMD
  21. $Contributor Disclosures - Facial fractures. All of the relevant financial relationships listed for the following individuals have been mitigated: Alexandra Willis (copyeditor, was previously employed by OPEN Health Communications). None of the other individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:.

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