Facial Fractures: Le Fort, Mandible, Zygoma, Orbit, and Nose Practice Questions

25 multiple-choice questions on Facial fractures: Le Fort, mandible, zygoma, orbit, and nose for paramedic and EMT students, from Chapter 34 (Face and Neck Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. The most commonly fractured bone of the face is the:

   1. A. Mandible
   2. B. Zygoma
   3. C. Nasal bone
   4. D. Frontal bone
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   Answer: C. Nasal bone

   The nasal bones project forward and are thin, so they break most often. The mandible is the second most commonly fractured facial bone.

2. After a fist to the bridge of the nose, a patient has a flattened nasal bridge and the distance between the inner corners of his eyes is widened. You should suspect:

   1. A. A simple nondisplaced nasal fracture
   2. B. A naso-orbito-ethmoid fracture
   3. C. An isolated zygomatic arch fracture
   4. D. A fracture of the mandible near the chin
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   Answer: B. A naso-orbito-ethmoid fracture

   Widening of the space between the inner corners of the eyes (telecanthus) with a flattened bridge indicates a naso-orbito-ethmoid fracture, which can injure the tear ducts, the cribriform plate (with CSF leak), and the brain coverings. A simple nasal fracture does not widen the eyes, and zygoma or mandible fractures are elsewhere.

3. A patient with a suspected mandible fracture has a large bruise under the tongue on the floor of the mouth. This finding:

   1. A. Is a normal finding after a punch
   2. B. Suggests a mandible fracture
   3. C. Rules out any fracture of the jaw
   4. D. Points to a nosebleed draining down
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   Answer: B. Suggests a mandible fracture

   A sublingual hematoma is a highly specific sign of a mandible fracture and can also enlarge to push the tongue up and back, threatening the airway. It is not normal after a punch, does not exclude fracture, and is unrelated to epistaxis.

4. A Le Fort III fracture is also called craniofacial disjunction because it:

   1. A. Fractures the mandible from the skull
   2. B. Involves only the bones of the nose
   3. C. Separates the facial bones from the cranium
   4. D. Separates the hard palate from the maxillary teeth
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   Answer: C. Separates the facial bones from the cranium

   Le Fort III runs across the orbits and zygomatic arches, detaching the whole midface from the skull. It carries the highest risk of airway compromise and associated brain injury.

5. A 14-year-old hit in the eye with a ball has an eye that will not look up, and he becomes pale and nauseated with a heart rate of 48/min when he tries. This reaction is most likely:

   1. A. An oculocardiac reflex from entrapment
   2. B. A sign of rising intracranial pressure
   3. C. Hypovolemia from facial bleeding
   4. D. A cardiac contusion from the impact
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   Answer: A. An oculocardiac reflex from entrapment

   In children with an orbital floor fracture that traps the inferior rectus, attempts to move the eye can trigger a vagal oculocardiac reflex with bradycardia, nausea, and fainting. This is an urgent surgical problem. Rising ICP would cause other neurologic signs, hypovolemia causes tachycardia rather than bradycardia, and a ball to the eye does not bruise the heart; the trigger here is the attempt to move the trapped eye.

6. Which finding is most characteristic of a Le Fort III fracture?

   1. A. Isolated movement of the upper teeth
   2. B. Numbness of the lower lip only
   3. C. Pain limited to the bridge of the nose
   4. D. A flattened, dish-faced appearance
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   Answer: D. A flattened, dish-faced appearance

   With a Le Fort III, and often a Le Fort II, the midface is driven backward and swells, flattening the profile into the classic dish face; CSF rhinorrhea and bruising around both eyes are common. Movement of the upper teeth alone fits a Le Fort I. Numbness of the lower lip points to the inferior alveolar nerve in a mandible fracture. Pain limited to the bridge of the nose fits an isolated nasal fracture.

7. A 40-year-old driver with midface injuries has clear fluid draining from his nose. This is most concerning for:

   1. A. A fractured nasal septum
   2. B. A cribriform plate fracture with CSF leak
   3. C. Irritation of the nasal mucosa from the blow
   4. D. An injury to the lacrimal duct
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   Answer: B. A cribriform plate fracture with CSF leak

   CSF rhinorrhea means the dura and the cribriform plate at the base of the skull are torn, opening a path for infection to the brain. A septal fracture causes bleeding rather than clear fluid.

8. A patient with a suspected cribriform plate fracture has clear fluid dripping from his nose and needs to sneeze. You should advise him to:

   1. A. Pinch his nose shut and sneeze hard
   2. B. Blow his nose firmly to clear the fluid
   3. C. Pack the nostrils tightly with gauze
   4. D. Sneeze with mouth open; no nose blowing
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   Answer: D. Sneeze with mouth open; no nose blowing

   With a CSF leak, raising pressure in the nose by blowing or sneezing against a closed mouth can push air and bacteria into the cranial vault (pneumocephalus, meningitis). Let the fluid drain onto loose gauze and avoid nasal packing or nasal airways.

9. When CSF is draining from the nose after a facial fracture, you should:

   1. A. Pack the nostrils firmly to stop it
   2. B. Pinch the nostrils and lean forward
   3. C. Allow it to drain and cover loosely
   4. D. Instill saline to dilute the drainage
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   Answer: C. Allow it to drain and cover loosely

   Blocking the drainage can raise ICP and trap bacteria near the brain, so let it flow and cover loosely with gauze. Pinching the nostrils is for anterior epistaxis without a suspected skull fracture.

10. A patient's jaw was wired shut after surgery last week. He is now nauseated and about to vomit. You should be ready to:

    1. A. Cut the wires or bands to clear the airway
    2. B. Suction through his nose as he vomits
    3. C. Turn him supine so the jaw stays protected
    4. D. Insert a nasal airway through each side
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    Answer: A. Cut the wires or bands to clear the airway

    Vomiting with the jaws wired together risks aspiration. Patients with intermaxillary fixation should carry wire cutters or scissors; cut the wires or elastic bands if vomiting or airway compromise occurs, position on the side, and suction. Nasal suction or nasal airways cannot clear vomit trapped behind wired teeth, and lying supine increases the risk of aspiration.

11. A patient with a mandible fracture has numbness of the lower lip and chin. This is due to injury to the:

    1. A. Inferior alveolar nerve
    2. B. Infraorbital nerve branch
    3. C. Facial nerve
    4. D. Hypoglossal nerve
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    Answer: A. Inferior alveolar nerve

    The inferior alveolar nerve runs through the mandible and supplies sensation to the lower teeth, lip, and chin. The infraorbital nerve supplies the cheek and upper lip and is injured in orbital and zygoma fractures.

12. The mandible is often fractured in more than one place because:

    1. A. It is thinner than any other facial bone
    2. B. It is not attached to any muscles
    3. C. It is a ring-shaped bone joined to the skull
    4. D. It has a poorer blood supply than the maxilla
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    Answer: C. It is a ring-shaped bone joined to the skull

    Like the pelvis, the mandible and skull form a ring, so a blow often breaks it at two points, such as the body on one side and the condyle on the other. It is a dense bone, not a thin one.

13. A 40-year-old woman was struck on the side of the face with a fist. Her cheek is flattened, she has numbness of the cheek and upper lip, and her eye cannot look upward. The most likely injury is a:

    1. A. Mandible fracture
    2. B. Zygoma fracture
    3. C. Le Fort I fracture
    4. D. Nasal fracture
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    Answer: B. Zygoma fracture

    A zygoma fracture flattens the cheek, can injure the infraorbital nerve, and can trap the eye muscles at the orbital rim and floor. Mandible fractures affect the bite and lower lip rather than upward gaze.

14. A zygomatic arch fracture can limit opening of the mouth because the fractured arch:

    1. A. Blocks the parotid duct
    2. B. Compresses the tongue
    3. C. Tears the masseter from the mandible
    4. D. Presses on the coronoid process
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    Answer: D. Presses on the coronoid process

    The depressed arch presses on the coronoid process and temporalis tendon as the jaw opens, causing pain and trismus. The parotid duct runs below the arch and does not control jaw movement.

15. An orbital blowout fracture usually occurs when:

    1. A. A sharp object penetrates the eyelid
    2. B. The mandible is driven upward into the skull base
    3. C. The head strikes the ground on the occiput
    4. D. A blunt object strikes the globe and orbital rim
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    Answer: D. A blunt object strikes the globe and orbital rim

    An object larger than the orbital opening, such as a fist or ball, suddenly raises pressure in the orbit and fractures its thin floor or medial wall. Occipital impact causes skull fractures, not blowout fractures.

16. A 24-year-old has a broken nose with swelling and slight deviation after a punch. His airway is clear and bleeding has stopped. Regarding the deformity, you should:

    1. A. Push it back to the midline right away
    2. B. Not try to straighten it in the field
    3. C. Pack the nostrils to hold it straight
    4. D. Tape a rigid splint tightly across it
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    Answer: B. Not try to straighten it in the field

    Nasal fractures are reduced later by a specialist after swelling settles; manipulation in the field causes pain, bleeding, and further injury. Apply a cold pack, have him sit up and lean forward if needed, and check for a septal hematoma and other facial fractures. Packing and tight splints are not field treatments.

17. Which finding is commonly associated with an orbital floor fracture?

    1. A. Numbness of the lower lip and chin
    2. B. Numbness of the forehead above the eye
    3. C. Numbness of the cheek below the eye
    4. D. Weakness of eyelid closure
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    Answer: C. Numbness of the cheek below the eye

    The infraorbital nerve runs through the orbital floor, so fractures there numb the cheek, side of the nose, and upper lip. Lower lip numbness points to the inferior alveolar nerve in the mandible. Forehead numbness points to the supraorbital nerve above the orbit, and weak eyelid closure is a facial nerve finding.

18. A patient with a suspected orbital blowout fracture should be told to avoid:

    1. A. Blowing the nose
    2. B. Closing both eyes
    3. C. Sitting upright
    4. D. Speaking in full sentences
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    Answer: A. Blowing the nose

    Blowing the nose forces air from the sinus into the orbit, causing orbital emphysema and swelling that can compress the globe. Sitting upright is appropriate for most isolated facial injuries.

19. A patient with an isolated nasal fracture has swelling and deformity. Prehospital care includes:

    1. A. Realigning the nasal bones manually
    2. B. Firm nasal packing in every case
    3. C. Cold packs and leaning forward
    4. D. Placing a nasopharyngeal airway
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    Answer: C. Cold packs and leaning forward

    Cold reduces swelling, and leaning forward keeps blood out of the airway. Reduction of the nasal bones is a hospital procedure, often delayed until swelling settles.

20. After an assault, a man has swelling of the face and severe pain when he chews. Which finding best helps you identify a facial fracture rather than soft-tissue swelling alone?

    1. A. Redness of the skin over the swelling
    2. B. Bruising that appears on the next day
    3. C. Pain that improves with an ice pack
    4. D. Malocclusion or a bony step-off
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    Answer: D. Malocclusion or a bony step-off

    A change in how the teeth meet, palpable step-offs, crepitus, or abnormal mobility indicate fracture. Redness, delayed bruising, and pain relief with cold occur with both soft-tissue and bony injury, so they do not distinguish them.

21. A 68-year-old man fell and has a nasal fracture with heavy bleeding. Which history is most important to obtain?

    1. A. Use of anticoagulant medication
    2. B. Previous cosmetic nasal surgery
    3. C. Tetanus immunization status
    4. D. Use of decongestant nasal sprays
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    Answer: A. Use of anticoagulant medication

    Anticoagulants such as warfarin and DOACs can turn a simple facial fracture into uncontrolled bleeding and raise concern for intracranial hemorrhage. Previous nasal surgery does not change management. Tetanus status matters for open wounds and decongestant spray use for recurrent nosebleeds, but neither changes immediate care as much as an anticoagulant.

22. Which statement about cervical spine injury in patients with facial fractures is correct?

    1. A. It can be excluded if the neck is not painful
    2. B. Facial fractures should raise suspicion of it
    3. C. It occurs mainly with fractures of the mandible
    4. D. It is unlikely without a neurologic deficit
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    Answer: B. Facial fractures should raise suspicion of it

    Force strong enough to break facial bones can be transmitted to the head and neck, so assess the spine in every such patient. Waiting for pain or deficits misses injuries in distracted or altered patients.

23. A patient with a mandible fracture in spinal motion restriction keeps gagging on blood. Which cervical collar concern is most important?

    1. A. It may compress the carotid arteries
    2. B. It may cause the fracture to heal poorly
    3. C. It may hide a zygoma fracture from view
    4. D. It may hold the jaw shut and trap blood
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    Answer: D. It may hold the jaw shut and trap blood

    A collar can press on an unstable jaw and limit mouth opening, so blood and vomit cannot drain. Manual stabilization and lateral positioning may be safer than a tight collar.

24. Which facial fracture pattern is most likely to be associated with a traumatic brain injury?

    1. A. Le Fort III
    2. B. Isolated nasal fracture
    3. C. Le Fort I
    4. D. Zygomatic arch fracture
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    Answer: A. Le Fort III

    Le Fort III separates the midface from the skull base and requires great force, so brain injury and basilar skull fracture are common. Isolated nasal fractures need much less force.

25. Facial fractures are seldom life-threatening by themselves; their main danger in the field is:

    1. A. Severe permanent facial disfigurement
    2. B. Associated airway and brain injury
    3. C. Hypovolemic shock from facial bleeding
    4. D. Infection of the fractured bones
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    Answer: B. Associated airway and brain injury

    The airway and the brain are the main threats, with spinal injury close behind. Facial bleeding can be heavy, but shock in a facial trauma patient should prompt a search for bleeding elsewhere.