Facial Fractures

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Facial Fractures

• Lisa Publicover
• August 2005

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Outline of Lecture

• Introduction
• Skeletal Anatomy
• Fracture Patterns
• Nasal
• Zygomatic
• Maxilla
• Blowout
• Frontal Sinus and Nasoethmoidal
• Mandibular
• Approach to a Suspected Facial Fracture

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Anatomy

• The face is composed of 14 bones
• Mandible (1)
• Vomer (1)
• Maxilla (2)
• Zygomata (2)
• Nasal (2)
• Lacrimals (2)
• Palatines (2)
• Inferior Nasal Conchae (2)

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Image from http//face-and-emotion.com/dataface/ph
ysiognomy/cranium.jsp
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The Mandible

• Lower jawbone
• Strongest facial bone
• Articulates with the temporal bone
• Contains foramens for the passage of nerves and
  blood vessels to the face

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The Volmer

• A small, narrow bone
• Forms the inferior part of the nasal septum

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The Maxilla

• Paired
• Form the upper jawbone
• Articulates will every other facial bone except
  the mandible
• Contains the maxillary sinuses
• Forms the inferior floor of the orbits
• Contains a foramen to allow passage of the
  maxillary/infraorbital nerve

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The Zygomata

• Paired
• Form the cheekbones
• Articulate with the temporal, frontal, and
  maxillary bones
• Their prominent position and shape renders them
  susceptible to injury

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The Nasal Bones

• Paired
• Join in the midline to form the nasal bridge
• They articulate with the frontal, maxillary, and
  ethmoid bones.

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The Lacrimal Bones

• Paired
• Small Fragile
• Located in the
• medial wall of each orbit
• Contains a small fossa,
• which houses the lacrimal
• apparatus

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The Palatine Bones

• Paired
• Located posterior to the maxilla
• Form the posterior part of the lateral wall of
  the nasal cavity

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The Inferior Nasal Conchae

• Paired
• Located within the nasal cavity
• Project medially from the lateral walls of the
  nasal cavity

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Fracture Patterns

• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus Nasoethmoid
• Mandibular

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Nasal Fractures ILateral Blow

• Cause Lateral force
• Signs Symptoms
• Pain
• Swelling
• Epistaxis
• Lacerations
• Respiratory Obstruction
• Treatment Emergency care, reduction referral
  if presentation is delayed.

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Fracture Patterns

• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus Nasoethmoid
• Mandibular

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Nasal Fractures IIOther

• Cause Anterior force
• Signs Symptoms Similar to lateral blow
  fractures
• Treatment Require referral for treatment.
  Treatment involves adequate reduction, packing
  (24-48h), and fixation with a plaster cast or
  splint.

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Fracture Patterns

• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus Nasoethmoid
• Mandibular

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Zygomatic Fractures

• Cause Blunt Force
• Signs Symptoms
• Pain
• Numbness of the cheek, infraorbital region
  upper teeth on injured side
• Eyelid swelling
• Inability to close mouth properly
• Swelling, Edema, Ecchymoses
• Flattened cheekbone
• Palpable depression at fracture site
• Treatment Reduction fixation

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Fracture Patterns

• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus Nasoethmoid
• Mandibular

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Maxillary Fractures

• Complex, Bilateral fracture that have an unstable
  floating fragment.
• Classified as LeFort I, II, or III based on the
  plane of the fracture.
• LeFort I Transmaxillary
• LeFort II Pyramidal/Subzygomatic
• LeFort III Craniofacial

Image from http//www.rad.washington.edu/mskbook/f
acialfx.html
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LeFort I Transmaxillary

• The fracture occurs along the nasal and maxillary
  floor
• Almost always involves the pterygoid process of
  the sphenoid bone
• May involve the maxillary sinuses
• The resultant floating component is the lower
  part of the maxilla and its teeth

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LeFort II Pyramidal/Subzygomatic

• Result from a downward force on the nose
• The fracture runs from the peak of the nasal bone
  laterally beneath the orbits.

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LeFort III Craniofacial

• Most severe
• Often associated with extensive soft tissue
  injury
• Large force is necessary to cause this type of
  fracture
• The resultant floating component is virtually
  the entire face

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Fracture Patterns

• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus Nasoethmoid
• Mandibular

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Blowout Fracture

• Downward displacement of the orbital floor with
  protrusion of orbital contents into the maxillary
  sinus.
• Caused by a force applied to the eye, which
  causes an increased intraorbital pressure.
• The elevated intraorbital pressure causes a
  fracture at the weakest point (posterior medial
  floor)
• Treatment involves surgical repair of the defect
  in the orbital floor

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Fracture Patterns

• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus Nasoethmoid
• Mandibular

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Frontal Sinus Nasoethmoid

• Caused by a force applied to the anterior aspect
  of the face
• Potentially dangerous (sharp edges can penetrate
  dura resulting in leakage of CSF)
• Treatment is surgical reduction, fixation, and
  repair of any damaged ligaments.

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Fracture Patterns

• Nasal
• Lateral Blow
• Other
• Zygomatic
• Maxilla
• LeFort I
• LeFort II
• LeFort III
• Blowout
• Frontal Sinus Nasoethmoid
• Mandibular

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Mandibular Fractures (1)

• Involved in 2/3 of all facial fractures
• Fractures are classified as open or closed
• Open With a break in the skin or mucosa
• Closed No break in the skin or mucosa
• Described as
• Oblique
• Transverse
• Comminuted
• Greenstick

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Mandibular Fractures (2)

• Signs Symptoms
• Pain
• Malocclusion
• Excessive salivation
• Dysphagia
• Swelling
• Crepitation
• Discoloration
• Deformity

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Approach to a Suspected Fracture

• History
• Symptoms
• Physical Examination
• Imaging

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History

• Cause of Fracture
• Degree of Force
• Specific Symptoms
• Time since injury
• Allergies
• Medications
• Etc.

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Physical Examination

• Symmetry/Deformity
• Lacerations/Abrasions/Ecchymoses
• Palpable step deformities
• Orbital rims
• Zygomatic arches
• Nose
• Frontal Bones
• Mandibular borders
• Movement of dental arches
• Fractured/Avulsed/Mobile teeth

• Visual disturbances
• Diplopia
• Reflexes
• Extraocular muscle function
• Acuity
• Fields
• Intranasal Inspection
• Hematoma
• Airway Obstruction
• CSF rhinorrhea
• Facial movement (including jaw excursions)
• Facial sensation

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Radiographic Examination

• Structure
• Mandible
• Condyle/Coronoid
• Ramus/Body
• Condyle Neck
• Symphysis
• Symphysis/Body/Ramus
• Maxilla Zygoma
• Frontal Orbital Floor

• Best View
• Lateral Oblique
• Waters
• Reverse Townes
• Occlusal
• Panoramic
• Waters
• Lateral
• Caldwell
• Waters

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References

• Grabb, W. Smith,J. (1979). Plastic Surgery (3rd
  Ed.). Little, Brown and Company Boston, MA
• University of Washington School of
  Medicinehttp//www.rad.washington.edu/mskbook/fac
  ialfx.html