A Comprehensive Review of Ultrasound-Assisted Closed Reduction of Facial Fractures

1. Introduction

Closed reduction of displaced facial fractures has been a cornerstone of craniomaxillofacial surgery for more than a century. For nasal bone fractures, zygomatic arch fractures, and selected condylar fractures, it remains the preferred initial approach: minimally invasive, performed under local or general anesthesia, and associated with low morbidity when successful [1,2,3]. Despite its clinical ubiquity, however, most closed reduction is performed based on palpation and assessment of the edematous face. The surgeon relies on the tactile sensation of the fracture reducing, the visual restoration of external contour, and, in the case of nasal fractures, the characteristic resistance and give of the mobilized bony fragments [4]. These endpoints are inherently operator-dependent and provide no objective, real-time confirmation of the underlying fracture alignment.

The clinical consequences of inadequate closed reduction are well recognized. Residual displacement of the nasal bones produces visible asymmetry and functional airway compromise that may require revision rhinoplasty, a much more invasive undertaking for the patient than the original closed procedure [5]. Incomplete reduction of the zygomatic arch can result in persistent cheek flattening, trismus from impingement on the coronoid process, and chronic pain [6]. The inadequately reduced condylar fractures carry risks of malocclusion, limited jaw opening, and temporomandibular joint dysfunction [7]. Reoperation in each of these contexts is associated with increased cost, greater technical difficulty, and potential for additional morbidity to the patient [8,9].

Intraoperative imaging has long been proposed as a solution to the diagnostic uncertainty inherent in closed reduction. Cone-beam computed tomography and conventional CT provide high-resolution three-dimensional data and have been shown to improve reduction quality when available in the operative setting, but they require dedicated infrastructure, expose the patient to ionizing radiation, interrupt the operative workflow, and are not accessible in many clinical environments [10]. Plain film radiographs have been used in situations where advanced imaging is not available but similarly requires radiation exposure [11]. Ultrasound represents an alternative that avoids each of these limitations. It is portable, radiation-free, low cost, available in most operating room settings and capable of generating real-time cross-sectional images of cortical bone surfaces without patient transfer or workflow disruption [12]. High-frequency linear transducers, now available in handheld point-of-care formats, are well suited to the imaging depths required for the nasal bones and zygomatic arch, and their use in the perioperative setting has expanded substantially across surgical and anesthetic specialties [13].

The diagnostic accuracy of ultrasound for facial fractures is established. A systematic review confirmed that its sensitivity and specificity for nasal bone fractures approach 90 to 100 percent and 98 to 100 percent, respectively, and are broadly comparable to CT for nasal bone, orbital walls, anterior maxillary wall, and zygomatic complex fractures [14]. More recently, the application of ultrasound has shifted from diagnosis toward therapeutic guidance, a growing number of investigators describing its use as a real-time intraoperative adjunct during the reduction maneuver itself, which is an application that offers the surgeon immediate feedback on the adequacy of the reduction before the patient leaves the operating room [15].

Guided by this framework, this narrative review evaluates the anatomical and technical basis for intraoperative sonography, reviews clinical outcomes across nasal bone, zygomatic arch, and condylar fracture subtypes, examines the role of handheld point-of-care ultrasound in the craniomaxillofacial trauma setting, and proposes a framework for integrating ultrasound guidance into standard facial fracture management. The review was conducted in accordance with the Scale for the Assessment of Narrative Review Articles (SANRA); a comprehensive literature search was performed using PubMed/MEDLINE, Scopus, and Google Scholar to identify relevant studies published through May 2026 [16]. Given the narrative nature of this review, formal risk-of-bias assessment and quantitative synthesis were not performed. Instead, the literature was synthesized to provide a comprehensive and balanced overview of the evolution of soft tissue scaffolds from biologic matrices to synthetic and hybrid materials. Limitations of the current evidence base and priorities for future research are also identified.

2. Rationale for Ultrasound Guidance

Bone is a strong ultrasound reflector, and the acoustic impedance mismatch at the cortical surface generates a bright, highly echogenic interface that is readily visualized with high-frequency linear transducers. Fractures disrupt this surface continuity, appearing as cortical step-offs, angulations, or discontinuities that can be detected and measured in real time during scanning. This physical property underlies the diagnostic utility of ultrasound for superficial bony injuries across multiple anatomical sites, and it is directly applicable to the facial skeleton, where the nasal bones, zygomatic arch, and anterior mandible lie within the optimal imaging depth of 12 to 15 MHz transducers [17,18].

The nasal bones are accessible from the dorsal surface in both the longitudinal and transverse planes. Longitudinal scanning along the nasal dorsum delineates the bony profile from the nasofrontal angle to the osseocartilaginous junction, and fracture lines and step deformities are identifiable as interruptions in the cortical reflection [19]. Transverse scanning provides a cross-sectional view of nasal width and lateral displacement. For zygomatic arch fractures, scanning in the coronal plane over the temporal region permits visualization of the arch in cross-section; the normal arch appears as a smooth, convex cortical line, and a fractured arch demonstrates inward angulation or cortical steps that can be quantified by measuring the angle of displacement relative to the contralateral arch (FIGURE 1) [20].

For condylar fractures, the subcondylar region is challenging to access and has been the subject of past investigation on visualization optimization during reduction and fixation [21]. It is accessible via a preauricular approach, though ultrasound image quality is constrained by the overlying temporal bone and masticatory musculature at deeper levels [22]. The condylar process can be identified with the mouth in the open position, which separates the condyle from the temporal bone and improves acoustic access. Ultrasound-guided percutaneous techniques for condylar fracture reduction exploit this window to identify fragment position and confirm reduction without the exposure required by open approaches [23].

The principal advantage of intraoperative ultrasound over tactile assessment is its objectivity. Palpation-based endpoints (the feel of the arch restoring its convexity, the sensation of nasal bones returning to the midline) are learned perceptual judgments that vary with operator experience, patient anatomy, and the degree of surrounding soft tissue swelling at the time of surgery. Ultrasound replaces these subjective impressions with a direct visual assessment of the cortical surface, enabling the surgeon to detect residual displacement that may not be apparent on external examination and to make iterative adjustments until an optimal position is confirmed. This rea-time feedback is particularly valuable for comminuted fractures, in which a single tactile endpoint may be impossible to define [20,24].

3. Current Methods for Evaluating Reduction Quality

The absence of a standardized, validated method for assessing closed reduction quality has meaningfully constrained the quality of evidence in this field. Studies have employed a heterogeneous array of outcome measures, including postoperative CT with geometric analysis of cortical displacement, external photographic scoring, patient-reported satisfaction questionnaires, reoperation rates, and surgeon-graded assessments, and the incompatibility of these endpoints across studies has made cross-study comparisons unreliable and precluded meaningful meta-analytic synthesis [15,25,26].

For zygomatic arch fractures, postoperative CT-based geometric analysis has been the most rigorously applied outcome measure in the comparative literature. The case-control study by Buller and colleagues measured the angle of cortical displacement on pre- and postoperative radiographic datasets, providing a quantitative endpoint that is examiner-independent, reproducible, and directly related to the mechanical result of the reduction maneuver [20]. This approach has the important advantage of isolating fracture position from the confounding influence of soft tissue swelling, which can obscure both the clinical impression of the result and the surgeon's intraoperative assessment. Its limitation is that it requires postoperative CT, adding radiation exposure and cost, and it captures a single timepoint rather than the dynamic process of intraoperative positioning [27].

For nasal bone fractures, photographic nasal profile scoring has been the most frequently used outcome measure in trials evaluating ultrasound guidance. The randomized controlled trial by Abu-Samra and colleagues employed blinded photographic assessment to compare postoperative nasal contour between ultrasound-guided and conventional reduction groups, demonstrating a statistically significant difference in profile scores that was not reflected in patient satisfaction questionnaire results [28]. This discordance is instructive: objective and patient-reported measures may capture different dimensions of outcome, and neither alone is sufficient to characterize the full impact of reduction quality on the patient experience. Patient satisfaction surveys, while directly relevant to quality of care, are susceptible to recall bias, response bias, and the phenomenon of response shift, in which patients adjust their expectations over time in ways that can obscure genuine differences in outcome [29,30].

Reoperation rate is a clinically meaningful but insensitive endpoint for evaluating reduction quality. A reduction that is suboptimal by radiographic or photographic criteria may not result in reoperation if the deficit falls below the threshold for surgical revision, yet it may still represent a clinically relevant impairment of form or function [31]. Conversely, the absence of reoperation in a small case series may reflect patient or surgeon preference rather than reduction adequacy. The use of reoperation as a primary endpoint therefore tends to underestimate the frequency of suboptimal reductions and is insufficient as a standalone quality measure [32].

The development of standardized, validated outcome measures for closed reduction of facial fractures represents one of the most important methodological needs in this field. Progress in ultrasound guidance research will require outcome tools that are sensitive to clinically relevant degrees of residual displacement, that correlate with patient-perceived functional and aesthetic results, and that can be applied consistently across institutions and study designs. Until such tools are developed and adopted, the evidence base will remain limited by the quality of the measurements on which it depends.

4. Ultrasound-Assisted Closed Reduction by Fracture Type

4.1. Nasal Bone Fractures

The evidence for ultrasound-assisted reduction is most mature for nasal bone fractures, where the superficial anatomy, the high imaging accuracy of ultrasound for cortical disruption, and the established clinical problem of inadequate closed reduction have converged to generate the largest body of comparative literature.

The highest-quality evidence comes from a randomized clinical trial by Abu-Samra and colleagues, who enrolled 68 patients with acute nasal bone fractures and randomly allocated them to conventional closed reduction or ultrasound-guided reduction [28]. Postoperative nasal profile scores, assessed by blinded external photography, were significantly higher in the ultrasound group (mean 2.72 versus 2.31). Patient satisfaction scores did not differ significantly between groups, a finding the authors attributed to the inherent difficulty patients face in objectively evaluating their own nasal contour, particularly in the early postoperative period before residual edema has fully resolved. This study provides level II evidence supporting the use of intraoperative ultrasound during nasal fracture reduction and remains the methodological benchmark for the field.

Yabe and colleagues conducted a prospective comparative study examining ultrasonography-assisted versus conventional closed reduction under local anesthesia [33]. Postoperative CT analysis did not demonstrate a statistically significant difference in bony alignment between the two groups, though the reoperation rate trended lower in the ultrasound arm (0 versus 2.8 percent, p > 0.05). The authors interpreted their findings as supporting a supplementary rather than replacement role for ultrasound, concluding that it should be used alongside, not instead of, visual inspection and palpation. This conclusion reflects an important principle that recurs across the zygomatic arch and condylar literature: ultrasound does not obviate the need for surgical judgment but augments it by providing objective feedback that the surgeon's hands alone cannot supply. The discordance between the CT findings of Yabe and the photographic results of Abu-Samra illustrates the measurement sensitivity problem discussed above: different outcomes capture different aspects of reduction quality, and a technology that improves one may show no signal on the other.

In the pediatric population, a prospective cohort study by Noy and colleagues enrolled 50 children with suspected nasal fractures, of whom 18 underwent closed reduction [34]. Ultrasound-guided reduction achieved satisfactory alignment in 82 percent of cases compared with 71 percent in those reduced without guidance, a clinically meaningful difference that did not reach statistical significance in this small sample. Ultrasound demonstrated sensitivity of 90 percent and specificity of 89 percent for fracture detection relative to expert clinical examination with interobserver reliability of 92 percent, indicating that point-of-care nasal ultrasound can be performed reproducibly by non-radiologists with appropriate training. The ACR Appropriateness Criteria for facial trauma imaging cite ultrasound sensitivity of 90 to 100 percent and specificity of 98 to 100 percent for nasal fractures, supporting its diagnostic role in this population and providing context for its intraoperative application [35].

Across the nasal fracture literature, a consistent technical theme emerges: ultrasound is most informative in the coronal and transverse planes over the nasal bridge, where cortical step deformities and lateral displacement are most readily visualized. A sterile probe cover and acoustic coupling gel are required for intraoperative use, and the examiner must account for soft tissue swelling, which can reduce image quality and introduce apparent irregularities that do not represent residual bony displacement [18,36].

4.2. Zygomatic Arch Fractures

The zygomatic arch presents a particularly compelling indication for ultrasound guidance, because the adequacy of closed reduction by the Gillies or Keen approach depends on restoring a smooth convex arch contour that is, by definition, not directly visualized during the procedure. Surgeons rely on palpation of the arch through the temporal skin and periosteum, and on the perception of resistance and movement as the elevator is applied. For simple M-shaped fractures with a single apex of inward displacement, this tactile feedback is generally reliable [20]. For geometrically complex or comminuted fracture patterns, in which multiple fragments must be repositioned simultaneously, superficial palpation provides an unreliable guide to the final reduction position [37]. For this reason, one of the authors (WS) prefers the Keen approach because a digit can be placed intra-orally, deep to the arch to palpate the sharp endings of a collapsed arch which then become smooth once reduction is complete.

The most methodologically rigorous study in the zygomatic arch literature is the retrospective case-control analysis by Buller and colleagues, which compared 16 patients who underwent closed reduction with intraoperative ultrasound to 60 controls treated without imaging guidance [20]. Geometric analysis of pre- and postoperative radiographic datasets demonstrated that intraoperative ultrasound significantly reduced the mean angle of postoperative displacement for all fractures (2.4° versus 5.3°; p = 0.004) and improved the overall grade of reduction (p = 0.03). Crucially, the benefit was concentrated in variable-type fracture patterns, where the difference in angular displacement was 1.6° versus 8.1° (p = 0.005), while M-shaped fractures showed satisfactory reduction quality with palpation alone and no measurable benefit from ultrasound guidance. This fracture-morphology-specific finding has important implications for clinical practice: it suggests that ultrasound guidance can be selectively deployed for the complex fracture patterns where it adds the most value, rather than applied universally to all closed reductions.

Kiwanuka and colleagues described a case series of three patients in which high-frequency ultrasound was used to confirm reduction of zygomatic arch fractures, providing early proof-of-concept data and establishing that cortical arch geometry can be reliably imaged intraoperatively with a linear transducer [38]. The series was small but technically detailed, and its description of the ultrasound approach, which includes the transducer positioned in the coronal plane over the temporal region with the arch visible in cross-section as a smooth hyperechoic line, has been reproduced and extended by subsequent investigators [39,40].

Sorenson and colleagues introduced the ultrasound-assisted zygomatic arch reduction (USA Reduction) technique, describing its application in two patients with comminuted zygomatic arch fractures treated via the Gillies approach under real-time intraoperative ultrasound guidance in a resource-limited setting [24]. In both cases, adequate reduction was confirmed sonographically at the conclusion of the procedure, and neither patient required postoperative CT for reduction verification. The authors proposed that the technique is particularly well suited to resource-limited environments where CT may not be readily available for either preoperative characterization or postoperative confirmation of the reduction result. The case series illustrates an important secondary benefit of intraoperative ultrasound: it may obviate the need for postoperative imaging in cases where reduction quality has been confirmed in real time, reducing radiation exposure and cost. Whether this represents a reliable and reproducible practice will require validation in larger series with longer follow-up.

4.3. Condylar Fractures

Ultrasound-guided management of condylar fractures occupies a distinct position in this literature, because it has been applied not merely as an adjunct to confirm reduction quality but as the primary navigational tool for a novel minimally invasive operative technique. Kucukguven and colleagues described a percutaneous ultrasound-guided approach to extracapsular condylar fractures in a series of seven patients, using the transducer to identify the displaced condylar fragment, guide the insertion of threaded Kirschner wires for manipulation and stabilization, and confirm the reduction position intraoperatively [23]. A custom-designed external fixator was used for postoperative maintenance of the reduction.

At long-term follow-up, all seven patients demonstrated normal occlusion, maximum interincisal opening exceeding 35 mm, and absence of pain during mandibular movements. No patient experienced facial nerve injury. This last finding warrants particular emphasis, as the marginal mandibular branch of the facial nerve is at meaningful risk during open subcondylar approaches, and avoidance of this exposure represents one of the principal theoretical advantages of a percutaneous ultrasound-guided strategy [41]. The series is small and the technique has not been reproduced by independent groups, but it demonstrates that ultrasound guidance can support anatomically precise manipulation in a region where direct visualization is otherwise unavailable without a formal open dissection.

The broader application of ultrasound to condylar fractures faces anatomical constraints not present in the nasal bone or zygomatic arch setting. The subcondylar region lies at greater depth, and the overlying temporal bone and masticatory musculature limit the acoustic window, particularly in patients with well-developed musculature or significant swelling [42]. Imaging quality is substantially position-dependent, and the optimal technique for obtaining reliable condylar views requires familiarity with the relevant anatomy and dedicated operator training [43]. These constraints make condylar ultrasound a more technically demanding application than nasal or zygomatic imaging, and the learning curve for this indication has not been formally characterized.

5. Emerging Applications for Point-of-Care Ultrasound in Craniomaxillofacial Trauma

The miniaturization of ultrasound technology has produced handheld point-of-care devices that can be deployed at the bedside, in the emergency department, and in the operating room without the infrastructure requirements of conventional ultrasound systems. These devices have expanded the potential application of diagnostic and interventional ultrasound to settings where traditional imaging platforms are unavailable, and their use in craniomaxillofacial trauma has been proposed as both a diagnostic and an intraoperative guidance tool [13].

Krasovsky and colleagues described the application of handheld point-of-care ultrasound in the craniomaxillofacial trauma setting, outlining its potential to supplement or in selected cases replace CT for the evaluation of minor facial fractures [13]. The authors identified the nasal bones, anterior maxillary wall, orbital floor, and zygomatic complex as fracture sites where ultrasound diagnostic accuracy is sufficient to support clinical decision-making, a conclusion consistent with the systematic review findings of Adeyemo and Akadiri, who confirmed that ultrasound sensitivity and specificity for these fracture sites are generally comparable to CT [14]. For more complex craniomaxillofacial injuries and fractures involving the posterior facial skeleton or skull base, CT remains the imaging standard, and ultrasound should not be applied as a replacement in these settings [44].

The potential for point-of-care ultrasound to reduce CT utilization in minor facial trauma has implications for patient radiation exposure, cost, and resource allocation, particularly in high-volume trauma centers and resource-limited environments [45]. A patient with an isolated nasal fracture who is taken to the operating room for closed reduction does not necessarily require a postoperative CT if intraoperative ultrasound has confirmed adequate alignment. Whether this practice is safe, reproducible, and acceptable to both patients and clinicians is a question that merits prospective evaluation.

Operator training is an important practical consideration for the broad adoption of point-of-care ultrasound in facial fracture management. Plastic surgeons and oral and maxillofacial surgeons do not routinely receive formal ultrasound training during their residencies, and the quality of intraoperative imaging will necessarily depend on the operator's familiarity with facial bone sonoanatomy and fracture patterns [46,47]. The development of standardized curricula and competency assessment tools for facial fracture ultrasound, analogous to those that exist for focused assessment with sonography for trauma (FAST) and other point-of-care applications, would support safe and consistent implementation across training levels and practice environments [48].

6. Technical Considerations, Operator Training, and Patient Selection

Intraoperative ultrasound of facial fractures requires a sterile field technique with a sterile probe cover and acoustic coupling gel. A high-frequency linear array transducer in the 12 to 15 MHz range is preferred for the nasal bones and zygomatic arch, providing spatial resolution sufficient to delineate cortical steps of clinically relevant magnitude [18]. The gel pad interposition technique, in which a standoff pad is placed between the transducer and the skin surface, has been described as a useful modification for anatomically contoured regions where direct transducer contact produces suboptimal coupling, and its use may improve image quality in the immediate postoperative period when tissue swelling is present [49].

For zygomatic arch imaging, the transducer is positioned in the coronal plane over the temporal skin with the beam directed inferiorly to capture the arch in cross-section. A normal, adequately reduced arch appears as a smooth, symmetric convex hyperechoic line. A residual step deformity manifests as an angular discontinuity in this line that can be measured in degrees relative to a baseline or to the contralateral arch [20]. Serial scanning during the reduction maneuver allows the surgeon to observe the arch anatomy in real time as the elevator is advanced and adjusted, providing an iterative feedback loop that is not available with tactile assessment alone [39].

Patient selection for ultrasound-guided closed reduction should account for factors that may limit image quality or reduce the likelihood of a successful closed reduction outcome. Significant soft tissue swelling in the immediate postinjury period can reduce image resolution and introduce apparent cortical irregularities that complicate interpretation [34]. In patients with extensive edema, delaying reduction until swelling partially resolves (a practice that is already standard for many nasal fractures) may improve both clinical assessment and ultrasound image quality [50]. Prior facial surgery, significant scarring, or implanted materials in the operative field may also affect imaging reliability [51].

The learning curve associated with intraoperative facial fracture sonography has not been formally characterized in the literature, and this represents an important gap. The quality of the reduction guidance provided by ultrasound is operator-dependent, and it is reasonable to expect that surgeons early in their experience with the technique will derive less benefit from it than experienced operators. Studies reporting positive outcomes with ultrasound guidance were conducted at institutions with dedicated interest in the technique, and the generalizability of these results to surgeons without specific training or experience in facial bone sonography is unknown. Formal assessment of the learning curve, ideally through a prospective training study with objective image quality and reduction accuracy endpoints, is needed to inform training requirements and credentialing standards.

7. Ultrasound Guidance Within the Broader Context of Intraoperative Imaging

Intraoperative imaging in facial fracture surgery sits within a broader landscape of technologies that aim to improve the precision of closed and open reduction procedures but is not yet perfectly implemented [52,53]. Cone-beam CT, and conventional intraoperative CT have each been evaluated as adjuncts to reduction, and a systematic review and meta-analysis of intraoperative these modalities for zygomatic arch fractures concluded that imaging-guided approaches achieved superior reduction quality compared with non-image-guided techniques [15]. However, many facilities lack traditional intraoperative CT. Thus, tangential views of the zygomatic arch using fluoroscopy have been shown to be helpful in determining if a zygomatic arch fracture has been properly elevated. In a series by Kobiena et al, when fluoroscopy was used intraoperatively to confirm the proper reduction of depressed arch fractures, follow up studies confirmed that the arch remained reduced and did not collapse postoperatively [54].

However, fluoroscopy requires small amounts of radiation exposure. Within this context, ultrasound occupies a specific niche defined by its portability, low cost, absence of ionizing radiation, and capacity for real-time dynamic imaging, properties that distinguish it from CT-based or fluoroscopic approaches and that may make it the modality of choice in specific clinical scenarios even if it does not provide the same degree of anatomical detail.

The concept of a tiered intraoperative imaging strategy, in which the choice of imaging modality is matched to the complexity of the fracture pattern and the available resources, offers a useful framework for integrating ultrasound into facial fracture practice. For simple M-shaped zygomatic arch fractures and straightforward nasal fractures in which palpation provides a reliable endpoint, imaging guidance may be unnecessary [39]. For geometrically complex or comminuted fractures, ultrasound guidance can improve reduction quality without the radiation exposure and infrastructure requirements of CT [20]. In the most complex cases, or in settings where ultrasound quality is limited by patient anatomy or operator experience, intraoperative CT remains the gold standard for confirmation of the reduction result [55].

The relationship between intraoperative imaging and the decision to proceed to open reduction is also relevant. A surgeon who detects residual displacement on intraoperative ultrasound has an actionable result: the reduction can be reattempted or, if closed techniques are insufficient, the decision to convert to an open approach can be made before the patient leaves the operating room rather than after a suboptimal result is identified on postoperative imaging. This real-time decision support represents a qualitative change in the surgeon's ability to manage the case, independent of any measurable difference in radiographic outcomes. The authors posit that ultrasound may be used to identify an inadequately reduced fracture which would benefit from open reduction.

Cost and resource considerations inevitably influence the adoption of any intraoperative technology. Ultrasound equipment suitable for intraoperative facial fracture guidance is available at costs that are substantially lower than intraoperative CT systems, and handheld point-of-care devices can be shared across clinical services [45]. Sterile probe covers add per-case consumable costs, and the time required for intraoperative scanning adds to operative duration. Formal health economic analyses comparing ultrasound-guided with conventional closed reduction, which accounts for the costs of equipment, training, added operative time, and the potential reduction in reoperation and postoperative CT utilization, have not been performed, and their findings would inform both institutional adoption decisions and payer coverage policies.

8. Gaps in Evidence and Priorities for Future Research

Despite a growing literature supporting the use of ultrasound guidance in facial fracture surgery, the evidence base remains immature, and several critical gaps must be addressed before ultrasound-assisted closed reduction can be recommended as a standard component of practice.

The most pressing need is for larger, adequately powered, prospective randomized controlled trials. Existing studies are predominantly small single-institution series, the largest comparative study includes only 76 patients, and none was designed with sufficient statistical power to serve as a definitive efficacy trial [20]. A well-designed RCT comparing ultrasound-guided with conventional closed reduction for each major fracture type with pre-specified primary endpoints, standardized technical protocols, and follow-up of sufficient duration to capture late complications and secondary procedures, would provide the level of evidence needed to support or refute routine adoption. For zygomatic arch fractures, the subgroup analysis findings of Buller and colleagues suggest that such a trial should stratify by fracture morphology, recognizing that M-shaped and variable-type fractures may respond differently to guidance interventions [20].

Standardized outcome reporting is essential for enabling cross-study comparisons and future meta-analyses. The current literature measures reduction quality using incompatible endpoints (angular CT measurements, photographic profile scores, reoperation rates, and patient satisfaction surveys) that cannot be synthesized across studies [15]. Agreement on a core outcome set for closed facial fracture reduction, including both objective radiographic measures and validated patient-reported instruments, would transform the quality of the evidence base and facilitate international collaborative research. The development of such a consensus outcome set, analogous to efforts in other surgical fields, should be a priority for the relevant specialty societies.

Comparative effectiveness research examining different ultrasound-guided techniques, probe types, frequencies, and coupling strategies is also needed. The existing literature does not permit reliable identification of technical parameters that optimize image quality or reduction accuracy, because these variables have been reported inconsistently or not at all. Prospective registry data capturing technical details of the intraoperative ultrasound examination alongside clinical outcomes would enable identification of the technique-specific predictors of success and the procedural variables most amenable to standardization.

The learning curve for intraoperative facial fracture sonography has not been formally characterized, and its documentation is an important prerequisite for training program development. A prospective study in which surgeons at varying levels of experience perform standardized ultrasound assessments of facial fracture models or cadaveric specimens with objective image quality assessment by blinded reviewers, would provide the data needed to define competency thresholds and inform credentialing requirements.

The condylar fracture literature is particularly sparse, and the ultrasound-guided percutaneous technique described by Kucukguven and colleagues has not been reproduced by independent groups. Multicenter prospective evaluation of this technique with rigorous reporting of patient selection criteria, technical details, and functional outcomes at standardized follow-up intervals, is needed to establish whether it can be safely generalized beyond the originating institution [23].

Finally, health economic analyses are needed to quantify the cost-effectiveness of intraoperative ultrasound guidance in facial fracture surgery. The costs of equipment acquisition, training, operative time, and consumables must be weighed against the benefits of improved reduction quality, reduced reoperation rates, and potential elimination of postoperative CT in appropriately selected patients. These analyses are necessary for informed institutional adoption decisions and for policy discussions about coverage of the technology in different health system contexts.

9. Conclusions

Closed reduction of facial fractures has for generations relied on tactile and visual cues that provide no objective intraoperative confirmation of alignment. Ultrasound offers a practical solution: portable, radiation-free, and capable of real-time cortical bone imaging at the point of care. The existing evidence consistently demonstrates that intraoperative ultrasound improves reduction quality for nasal and zygomatic arch fractures, with the greatest benefit for geometrically complex patterns in which palpation alone is insufficient. Emerging data support its extension to condylar fractures and point-of-care diagnostic applications. Adequately powered multicenter trials and standardized outcome reporting are the most urgent research priorities. As the evidence base matures, ultrasound guidance should become a routine part of the facial fracture surgeon's intraoperative armamentarium.