Textbook of Urgent Care Medicine, Chapter 36, Facial Injuries

Chapter 36 | Original author: Sean M. McNeeley

Originally published in 2014. Substantially updated and clinically reviewed in 2026.

Introduction

Although facial injuries can span the spectrum of minor abrasions to severe maxillary fractures and respiratory compromise, most can be handled in an urgent care setting. Understanding the warning signs of more serious injuries described in this chapter is important to the decision to treat or transfer.

The initial evaluation must first identify threats to the airway, vision, neurologic function, and cervical spine. Definitive imaging and management of major facial fractures usually belong in an emergency department or trauma center.

Presentation

Facial injuries can present alone or along with other trauma, particularly trauma involving the head, neck, and upper body. Patients with facial injuries usually seek care because of concerns about a poor cosmetic outcome. Understanding a patient’s motivation is helpful, but evaluation must include consideration of other more serious—even life-threatening—issues that may also be present.

Triage Pearls

• Nonfacial symptoms increase concern regarding serious injury (e.g., headache, nausea, emesis, neck pain, blurred vision, chest pain, dyspnea, abdominal pain, or extremity swelling or deformity).
• Cervical spine immobilization should be considered on the basis of severity and mechanism of injury, neck pain, paresthesias, or any other distracting injury, including altered mental status caused by drugs or alcohol.
• Vital signs should be assessed.
• Any instability of vital signs requires immediate assessment by a physician.
• Bleeding or fracture can compromise airway and breathing.
• The amount and location of bleeding should be evaluated.
• Raccoon eyes (Figure 1), Battle sign, and hemotympanum suggest a possible basilar skull fracture.

• Problems with eye movement may indicate an orbit fracture.
• An inability to move the jaw suggests a possible mandibular fracture or dislocation.
• The patient should be checked for possible cerebrospinal fluid rhinorrhea or otorrhea.
• Stridor, expanding facial or neck swelling, uncontrolled hemorrhage, hypoxemia, or altered mental status warrants immediate EMS transfer with airway readiness; do not delay transport for routine radiographs.
• Sudden vision loss, a relative afferent pupillary defect, proptosis with a tense orbit, or a suspected open globe is an ocular emergency. Protect the eye from pressure, activate emergency transfer, and involve ophthalmology promptly.

History Pearls

• The mechanism of injury will be a guide to likely injuries and their severity.
• Other injuries may provide confirmation of the severity of the injury:
  • Neck pain
  • Associated head trauma
  • Scalp lacerations or hematoma
• Possible vision-related problems include double or blurred vision, floaters, eye pain, and other changes.
• Hearing changes may arise from a ruptured tympanic membrane, foreign body, or other local damage.
• Bleeding or cerebrospinal fluid from the nose or ears may be present.
• Patient concerns and expectations of injury outcomes should be addressed; cosmetic appearance is often a patient priority.
• Past injuries should be noted.
• Current use of blood thinners (warfarin, clopidogrel, aspirin, anisindione, dabigatran, enoxaparin) should be assessed.
• Neurologic symptoms should be carefully evaluated:
  • Loss of consciousness
  • Headache
  • Dizziness
  • Behavior change
  • Confusion
  • Memory loss (especially retrograde)
  • Numbness or paresthesia
• Document the timing of injury, anticoagulants or antiplatelet agents, vomiting, seizure, worsening headache, and the presence of an adequate observer at home. Patients with possible head injury need a separate head-injury assessment and disposition decision.

Physical Exam Pearls

• General: vital signs and overall appearance.
• Skin: location and degree of bruising (especially raccoon eyes and Battle sign), and location and depth of lacerations.
• Head, eyes, ears, nose, and throat:
  • Swelling around eyes, ears, nose, maxilla, or mandible
  • Crepitus as a possible indicator of fracture, with inappropriate air present in the subcutaneous tissues
  • Excessive mobility and potential fracture of the nose, maxilla, and mandible
  • Innervation of the infraorbital, facial, and trigeminal nerves
  • Eyes: visual acuity should be checked, and the exam should include an assessment of the pupils, eye movement, lower and upper lids (be sure to evert the upper lid), and the possible presence of hyphema and subconjunctival hemorrhage.
  • Fluorescein staining should be done if there is no obvious penetration.
  • Ears: the tympanic membrane should be confirmed intact before irrigation; perichondrial or retroauricular hematomas (Battle sign) should be evaluated.
  • Internal exam of the nose for septal deviation, hematoma, or lacerations.
  • Mobility, localized tenderness, or deformity of the maxilla.
  • Mandible: assess the temporomandibular joint and dental alignment, along with the patient’s ability to open and close the mouth; inspect the mouth for associated open fractures.
• Neck: cervical spine tenderness (centrally) and range of motion should be assessed only if cervical spine injury is unlikely; immobilize when cervical injury is possible.
• Complete musculoskeletal exam to rule out associated injuries, including chest wall and ribs.
• Cardiopulmonary: heart sounds, rubs, decreased breath sounds, and stridor.
• If an open globe is suspected, avoid ocular pressure, tonometry, ultrasound contact, and lid manipulation that could worsen injury. Place a rigid protective shield without pressure and arrange emergent evaluation.
• When there is orbital trauma, document visual acuity in each eye, pupils, relative afferent pupillary defect if present, extraocular movement, diplopia, proptosis, and infraorbital sensation. Do not delay transfer for a complete exam when the patient is unstable.

Testing Pearls

• Crepitus, deformity, and tenderness can help guide imaging.
• Plain films rarely change nasal fracture management; however, the clinician should look for and document the presence or absence of septal hematoma.
• Concerns for serious fractures (maxilla, orbit) are best evaluated by computed tomography (CT).
• Mandibular fractures are best seen on panoramic radiographs or CT.
• For suspected frontal, orbital, midface, or mandibular fractures, maxillofacial CT without IV contrast is generally the preferred imaging examination. Patients who need CT for suspected significant injury should be referred to an emergency department rather than delaying care for limited urgent-care imaging.
• An isolated uncomplicated nasal fracture is usually a clinical diagnosis and does not need routine nasal radiographs; CT is reserved when associated facial or intracranial injuries are suspected.
• Assess possible head injury separately. In anticoagulated patients or those with neurologic warning signs, a normal facial examination cannot substitute for appropriate emergency head-injury evaluation.

Diagnosis Pearls

Forehead

Fractures are suggested by excessive softness and a severe mechanism of injury.

• Suspected frontal sinus or anterior skull-base fracture requires emergency assessment, particularly with a depressed contour, clear nasal drainage, or neurologic findings. Associated intracranial and cervical injuries must be considered.

Eyes

• A foreign-body sensation should be evaluated by everting the upper lid.
• A corneal abrasion feels like a foreign body, and fluorescein uptake will reveal the presence of such an injury.
• An orbital fracture is characterized by double vision, eye muscle entrapment, crepitus, bruising, and infraorbital anesthesia.
• Globe injury is apparent from gross injury, extruding vitreous humor, or hyphema.
• An apparently intact exterior does not exclude serious globe injury. Hyphema, a peaked pupil, irregular globe contour, marked reduction in vision, or a suspected penetrating injury warrants emergency ophthalmologic evaluation.
• Children with restricted gaze, pain on eye movement, nausea, vomiting, or bradycardia after orbital trauma may have a trapdoor fracture with muscle entrapment despite minimal bruising; arrange emergency evaluation.

Ears

• The ear is composed of cartilage skeleton and overlying skin, and hematoma formation is common.
• Lacerations often involve the cartilage.
• Auricular hematomas require prompt drainage with an appropriate bolster dressing to prevent reaccumulation and cauliflower-ear deformity; arrange ENT or experienced procedural management and early reassessment.

Nose

• Nasal fracture is the most common facial fracture; it is often mobile and tender, with bruising under the eyes.
• Septal hematoma is visible on internal exam.
• Epistaxis management is covered in Chapter 8 (“Epistaxis”).
• Inspect both sides of the septum in every suspected nasal fracture. A fluctuant, purplish septal swelling is a septal hematoma until proven otherwise and requires immediate drainage by a qualified clinician.

Maxilla

• Isolated zygomatic fracture may be displaced or depressed, usually palpable.
• Le Fort classification of fractures:
  • Type I is characterized by a horizontal fracture through the lower maxilla, with the upper teeth moving like a denture.
  • In a type II fracture, the nasomaxillary segment is separated from the zygoma and orbits; the nasal area is included.
  • A type III fracture involves separation of the facial bones from the cranial skeleton and involves the base of the orbits as well. It is highly associated with intracranial injury and airway compromise.
• Midface mobility, malocclusion, altered infraorbital sensation, and significant facial swelling require CT-capable hospital evaluation. Avoid unnecessary manipulation of an unstable midface.

Mandible

• With dislocation, the sensation of bite is off and there is often crepitus at the temporomandibular joint.
• Fractures are accompanied by pain with movement and palpable deformity (Figure 2).

• Malocclusion, trismus, gingival bleeding, numbness of the lower lip, or a step-off in the dental arch should raise suspicion for mandibular fracture, even if external swelling is limited.

Treatment and Disposition Pearls

Forehead and Facial Skin

• Bleeding, even if it is brisk, responds well to pressure.
• Uncomplicated forehead, lateral face, and chin lacerations are usually repaired in the urgent care setting.
• These lacerations are often amenable to dermal adhesive, though caution is required to ensure control of dripping of the wound glue, especially around the eyes and mouth.
  • Cosmesis is dependent on hemostasis of the wound prior to the application of the tissue adhesive and adequate approximation of wound edges.
  • Complex or stellate wounds or wounds under tension or perpendicular to tension lines are not good candidates for tissue adhesive.
• Other lacerations can be closed with 6-0 nylon, polypropylene, or absorbable sutures.
• Alternate methods for uncomplicated, relatively straight wounds include subcuticular sutures.
• Choosing a color that is easy to see on the patient’s skin and surrounding hair can help with both repair and suture removal.
• Irrigate adequately, assess contamination and retained foreign bodies, document facial nerve function when relevant, and update tetanus prophylaxis as indicated. Most uncomplicated clean facial lacerations do not need routine systemic antibiotics.
• Facial nonabsorbable sutures generally require removal at approximately 3–5 days, adjusted for wound location and tension; give wound care, scar protection, and return precautions.

Eyes

• Referral to plastic surgery should be considered for lid lacerations when the tear duct may be involved. Superficial lacerations with minimal lid involvement can often be repaired with 6-0 nylon or polypropylene.
• Foreign bodies and penetrating trauma require specialized eye treatment.
• A possible orbital fracture is best evaluated by CT scan to verify the fracture and extent of injury (Figure 3).
• Isolated orbital fractures without entrapment or nerve damage are often treated conservatively, though specialty consultation should be obtained.

• Do not prescribe prophylactic antibiotics routinely for an uncomplicated closed, nonoperative orbital fracture. Consider prophylaxis only for associated open or contaminated wounds or another specific infectious indication.
• Patients with possible orbital fractures should avoid forceful nose blowing until cleared. Any reduced vision, suspected globe injury, entrapment, or signs of orbital compartment syndrome require immediate emergency evaluation.

Ears

• Pinna: cartilage should not be sutured routinely in simple injuries; complex lacerations or significant skin maceration require referral to otolaryngology or plastic surgery.
• A fluctuant auricular hematoma should receive prompt evacuation and compression/bolster management by a clinician skilled in the procedure, with recheck within 24–48 hours; routine observation without drainage risks deformity.
• Tympanic membrane: in the case of rupture, ensure that no foreign matter is present and arrange follow-up with an ear, nose, and throat (ENT) specialist.
• Most clean traumatic tympanic membrane perforations heal with dry-ear precautions and observation. Routine oral antibiotics are unnecessary; use nonototoxic topical drops for contaminated injury or infection when indicated. Avoid irrigation and aminoglycoside-containing otic drops.

Nose

• A superficial laceration can be treated like other facial lacerations.
• ENT consultation should be considered for deeper wounds or if there are concerns for a poor cosmetic outcome.
• Bruising is likely to increase over the first few days and spread around the eyes.
• Once swelling is present, setting mildly displaced fractures should not be attempted, because it may worsen displacement due to asymmetric swelling.
• The patient should follow up with an ENT specialist within 10 days.
• A patient with septal hematoma, open fracture, or persistent bleeding should be sent for immediate ENT evaluation or transported to an emergency department.
• An uncomplicated nasal fracture causing deformity or obstruction may need reduction after swelling subsides, usually within about 2 weeks; arrange timely ENT follow-up rather than routinely obtaining an X-ray.
• A suspected septal hematoma requires immediate drainage. Do not send the patient home with delayed follow-up, because septal cartilage necrosis can occur.

Maxilla

• Maxillary lacerations can be treated similarly to other facial lacerations; fractures may be severe and should be evaluated carefully.
• Le Fort fractures need further evaluation and may require surgical intervention for stabilization. Le Fort type 3 fractures have a high incidence of intracranial involvement and must be evaluated for neurologic and airway compromise.
• Suspected unstable maxillary, zygomatic, or Le Fort fracture requires emergency department transfer for CT imaging, airway assessment, and maxillofacial consultation.

Mandible

• Dislocations without a fracture can frequently be reduced by applying steady pressure on the lower molars and the proximal mandible with gloved hands.
• Nondisplaced closed mandibular fractures are often treated by soft diet and close follow-up. Open fractures and those that are pulled out of alignment by local muscles need urgent consultation and may require hospital admission or surgical repair.
• Attempt reduction of a temporomandibular joint dislocation in urgent care only if it is clearly uncomplicated, there is no fracture concern, and the clinician has suitable training and analgesia. Suspected fracture, airway risk, uncontrolled pain, or failed reduction warrants ED evaluation.

Urgent Care Disposition

Urgent Care Disposition in Facial Trauma

Medicolegal Pearls

• In orbital injuries, the clinician should evaluate and document visual acuity, extra-ocular movement, reactivity to light, and integrity of the globe.
• Lacerations in close proximity to the eye should have documentation about the lacrimal system.
• Airway patency is important to evaluate and document in patients with maxillary and mandibular injuries.
• In nasal fractures, the lack of septal hematoma should be documented.
• Fractures of the superior orbit are rare, and they indicate a very significant mechanism of injury.
• Record pertinent negatives as well as positives: visual acuity, pupils, ocular motility, septal examination, dental occlusion, cranial nerve findings, mental status, anticoagulant use, and return precautions. Document the receiving facility and handoff for transferred patients.

References

1. American College of Radiology. ACR Appropriateness Criteria: Imaging of Facial Trauma Following Primary Survey. Accessed October 30, 2026.
2. Most SP. Nasal Fractures. Merck Manual Professional Edition. Updated April 2026.
3. American Association for the Surgery of Trauma Critical Care Committee. Antibiotic prophylaxis in injury: clinical consensus document. Trauma Surg Acute Care Open. 2024.
4. Jan TA. Traumatic Perforation of the Tympanic Membrane. Merck Manual Professional Edition. Updated June 2026.
5. Dinces EA. How To Drain an Auricular Hematoma. Merck Manual Professional Edition. Updated May 2025.
6. American College of Emergency Physicians. Clinical policy: critical issues in the management of adult patients presenting to the emergency department with mild traumatic brain injury. Ann Emerg Med. 2023;81(5):e63-e105.
7. American Academy of Ophthalmology. Open Globe Injury: Assessment and Preoperative Management. 2020.
8. Peterson CL. 3 Procedures for Eye-mergencies. American Academy of Ophthalmology. July 8, 2025.
9. Forsch RT, Little SH, Williams C. Laceration Repair: A Practical Approach. Am Fam Physician. 2017;95(10):628-636.
10. American Academy of Ophthalmology. Orbital Floor Fractures. EyeNet.