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Facial Fracture BasicsNasal FracturesNaso-orbital-ethmoidal FracturesFrontal Sinus FracturesZygomatic FracturesMaxillary FracturesOrbital Fractures
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A
- AirwayB
-
Breathing
C
-
Circulation / Hemorrhage
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Local PressureDressings / PackingReduction Of Facial FracturesEndovascular ConsultationLigation Of Vessels◦
IMAX
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C-Spine Injury◦
10% C-Spine Fracture
Head Injury◦
50% -
Loss of Consciousness
◦
5% Significant Intracranial InjuryOcular Injury◦
25% -
Some Degree of Injury
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Pain / TendernessCrepitus From Bony FracturesHypoesthesiaParalysis MalocclusionVisual Disturbances
DeformityObstructive RespirationLacerationsBleedingContusionsFacial Asymmetry
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Tetanus ProphylaxisStructures◦
Facial Nerve◦
Trigeminal Nerve◦
Parotid Duct◦
Lacrimal System
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Precise anatomic diagnosisDirect fracture exposureReduction / rigid internal fixation◦
Mandible fracture stabilization◦
Reconstruction of horizontal and vertical facial buttresses
Primary bone graftingPeriosteal and soft-tissue suspension and repair
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Upper Vault◦
nasal bones, ethmoid, superior edge of septum, vomer
Middle Vault◦
upper lateral cartilages, most of septum, maxilla
Lower Vault◦
alar cartilages, inferior edge of septum
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EdemaCrepitusPeriorbital EcchymosisEpistaxisInternal And External LacerationsWidened Nasal BridgeSeptal Hematoma
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Lateral Impact Injuries◦
Unilateral vs. Bilateral
Frontal Impact Injuries◦
Plane I◦
Plane II◦
Plane III
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Early Versus Delayed TreatmentClosed Reduction (Local vs. General)Drainage of Septal HematomaSimple Repositioning of Deviated Nasal Bones and Septum◦
Completion Of The Fracture
Internal Packing and External Splint
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Plane I◦
edema / ecchymosis distal nasal bridge and tip◦
possible septal distortion◦
closed reduction with internal support◦
possibly may require secondary septorhinoplasty
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Plane II◦
Increased Comminution of the Nasal Pyramid◦
Bilateral◦
Possible “Saddling”◦
Initial Closed reduction◦
May Require Delayed Septal Reconstruction With Grafts
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Plane III◦
Extend Into Pyriform Aperture And Medial Orbital Rim
ie. Naso-Orbital-Ethmoidal Fractures◦
Open Reduction an Internal Fixation of Frontal Process of Maxilla◦
Transnasal Reduction of Medial Canthal Ligaments
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Occur In Up To 70%◦
Deviated Nasal Pyramid◦
Nasal “Hump”◦
Septal Deformity With Respiratory Obstruction
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Interorbital “Space”◦
two ethmoidal labyrinths◦
superior and middle turbinates◦
perpendicular plate of ethmoid
Medial Orbital Wall◦
anteriorly -
lacrimal bone and lamina papyracea
◦
posteriorly -
body of sphenoid
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Interorbital space displaced backwardsMedial Canthal Tendon and Lacrimal Apparatus frequently injuredMay extend into:◦
cribiform plate and anterior cranial fossa◦
optic foramen
Associated Orbit and Midface Fractures Common
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Flat noseSwollen medial canthal areaTelecanthus (12-20%)Lack of skeletal support on palpation of noseCSF leakPositive eyelid traction test
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Normal intercanthal distance (Stranc)◦
White males:
33-34mm
◦
Females:
32-33mm
Consider >35mm abnormal (Manson)
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Type I - Single central segment
Type II - Comminuted central segment
Type III - Avulsed medial canthal tendon
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1
Isolated injury to bony naso-orbital region
2
Associated fractures of the central maxilla
3
Associated LeFort II and III4
Naso-orbital fractures with orbital dystopia
5
Naso-orbital fractures with bone loss
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Early open reductionFour Objectives:◦
correct epicanthal folds◦
restore bony contour◦
reestablish lacrimal system continuity◦
medial canthoplasty / canthopexy
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Wide Exposure◦
coronal incision◦
“open sky”
-
transverse across root of nose
◦
vertical midline nasal◦
subciliary◦
buccal sulcus◦
extend existing lacerations
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Correct nasofrontal separation◦
Elevate nasal bones
Reduce comminuted nasal bonesBone graft where neededExplore septumStabilize nasomaxillary buttresses
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Medial Canthus Repair◦
Transnasal Wires
Through central fragmentPosterior and Superior to lacrimal apparatusThree sets of wire
bone reductionmedial canthus reattachmentreapproximate skin to nasal skeleton
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Incidence◦
<20%
Routine exploration not justifiedPersistent dacryocystitis of obstruction◦
Dacryocystorhinostomy
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Telecanthus◦
related to inadequate / delayed treatment
Lacrimal system obstruction / infectionMeningitis
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Begin to Develop At 2 Years of Age◦
Extension of the Ethmoid Air Cells
Radiographically Evident At ~ 8 YearsDo Not Reach Adult Size Until 12 or Older10% - Unilateral Development4% - Absent All TogetherDrain Into Middle Meatus
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Usually Small◦
5 cm3 in adults
Anterior Wall Thicker Than PosteriorClose To Other Structures◦
Posteriorly (cribiform plate, dura mater, frontal lobes)◦
Inferiorly (orbit, nasofrontal duct)
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Supraorbital / Temporal vs Frontal Sinus
Anterior Wall and/or Posterior Wall
Nasofrontal Duct
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Signs And Symptoms◦
Forehead Laceration◦
CSF Rhinorrhea◦
Supraorbital Nerve Anesthesia◦
Depressed Frontal Region◦
Subconjunctival Ecchymosis
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X-Ray◦
Air Fluid Levels
CT Scan◦
Axial and Coronal Images
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Operative Indications◦
Anterior Table Displacement With Contour Change◦
Nasofrontal Duct Involvement◦
Displaced Posterior Table
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Nasofrontal Duct Injury◦
Remove Mucosa◦
Burr Inner Cortex◦
Occlusion Of Duct◦
Sinus Obliteration
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Posterior Table◦
Cranialization1
Bicoronal Approach2
Preserve Pericranial Flap3
Dural Repair4
Remove Sinus Mucosa5
Obliterate Nasofrontal Duct6
Remove Intersinus Septum And Posterior Wall7
Pericranial Flap To Floor Of Sinus
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Early (within 6 months)◦
Frontal Sinusitis◦
Meningitis
Late ◦
Mucocele◦
Mucopyocele◦
Brain Abcess◦
Osteomyelitis
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Incidence Of Late Complications◦
Freihofer
71 Fractures2 Patients - Meningitis1 Patient - Mucopyocele With Osteomyelitis Of Frontal Bone
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Tetrapod Structure◦
Frontal Bone◦
Temporal Bone◦
Maxilla◦
Greater Wing Of Sphenoid
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Muscular Attachments◦
Masseter◦
Temporalis◦
Zygomaticus◦
Zygomatic Head of Quadratus Labii Superioris
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Circumorbital Swelling / EcchymosisSubconjunctival HemorrageAbnormal Sensation V2 DistributionDiplopia or Globe DisplacementIncreased Facial Width
Depressed Malar ProminencePalpable Step DeformitiesUnilateral EpistaxisHematoma Upper Buccal SulcusTrismus Due To Coronoid Process Impingement
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X-Ray◦
Water’s View Most Useful
CT Scan◦
Coronal Cuts For Orbital Anatomy
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Knight1
Undisplaced2
Arch Fractures3
Unrotated Body Fractures4
Medially Rotated Body Fractures5
Laterally Rotated Body Fractures6
Complex Fractures -
Additional Fractures Across Zygoma
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Manson◦
Low Energy
minimal displacementdo not require operative reduction
◦
Middle Energy◦
High Energy
often part of panfacial fractures
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Undisplaced◦
Nonoperative
Displaced◦
Isolated Zygomatic Arch
-
Gilles Elevation
◦
Orbitozygomatic Fractures
-
Open reduction and Stabilization
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BleedingInfectionExacerbation of Sinus DiseaseMalfunction of Extraocular MusclesBlindness
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Nonunion / MalunionDiplopia (10% initial, 5% permanent)Persistent V2 Anesthesia (24%)Orbital DystopiaChronic Maxillary Sinusitis (4-7%)
ScarringEctropionProblems With Mandible MotionEnophthalmos (3%)Soft Tissue Descent With Loss of Malar Prominence
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LeFort I◦
Transverse Fracture That Separates Maxillary Alveolus From Midface Skeleton◦
Runs Above Roots of Maxillary Teeth, Across Lower Pyriform Aperature, and Severs Pterygoid Process
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Lefort II◦
“Pyramidal”
Fracture of Maxilla
◦
Separates Nasomaxillary Segment from Zygomatic and Upper Lateral Midface◦
Fracture Line May Go Above or Beneath Medial Canthal Ligament Insertion◦
Lacrimal System May Be Involved
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LeFort III◦
Craniofacial Dysjunction◦
Zygomaticofrontal Junction, Traverses Lateral, Inferior, and Medial Orbit, Separates Frontal Process of Maxilla From Frontal Bones
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EpistaxisEcchymosis (periorbital, conjunctival, and scleral)Malocclusion With Anterior Open BiteBuccal Mucosa HematomaTear in Intraoral Soft TissuesElongated, Retruded Appearance◦
“Donkey-Like”
Facies
CSF Leak in 25-50% of LeFort II and III
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X-Rays◦
Bilateral Maxillary Sinus Opacification◦
Pterygoid Plate Fracture On Lateral Projection◦
Fracture Through ZF and Nasofrontal Suture
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Goals◦
re-establish midfacial height and projection◦
establish occlusal relationship◦
maintain integrity of nose and orbits
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Intermaxillary FixationOpen Reduction◦
LeFort I
Bilateral Buccal Sulcus Incisions◦
LeFort II and III
Coronal and Lower Eyelid Incisions
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Rigid Internal Fixation◦
Frontal Bone as a Guide◦
Mandibuar Ramus Dictates Facial Height◦
Stabilize Vertical Buttresses◦
Bone Grafts If Necessary
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Early◦
Extensive Hemorrhage◦
Airway Obstruction◦
Infection◦
CSF Leak ◦
Blindness
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Late◦
Palpable Hadware◦
Non-Union / Malunion◦
Plate Exposure◦
Lacrimal System Obstruction◦
V2 Anesthesia◦
Devitalized Teeth◦
Extra-Occular Muscle Imbalance
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Late◦
Diplopia◦
Enophthalmos◦
Orbital Dystopia◦
Change In Facial Appearance
Facial height and width◦
Nasal Obstruction◦
Malocclusion
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8% of LeFort fractures
Younger vs. Older◦
<30 years
midline fracture◦
>30 years
sagittal fractures adjacent to midline or alveolus
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Stabilize before IMFOpen reduction of palatal roofPyriform aperture plate to unite maxillary segementsDental splints to prevent occlusion
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Seven Bones◦
Frontal◦
Maxilla◦
Zygoma◦
Ethmoid◦
Lacrimal Bone◦
Greater and Lesser Wings of Sphenoid◦
Palatine
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Inferior Wall◦
Vulnerable◦
Thin Maxillary Roof◦
Infraorbital Canal◦
Curvature of Floor
Medial Wall◦
Thin Lacrimal Bone And Lamina Paprycea of Ethmoid◦
Medial Canthal Ligament and Lacrimal Sac
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Pure Blowout
-
only orbital floor or medial wall injured
Impure Blowout
-
associated orbital rim fractures
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DiplopiaEnophthalmosInferior Displacement Palpebral FissureAnesthesia of Infraorbital NerveOrbital Emphysema
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Diplopia◦
Commonly on Upward Gaze◦
Primary (Central Gaze) or Secondary (Perpheral)◦
Mechanical (incarceration of infraorbital tissue) or Nonmechanical (paresis)◦
Forced Duction Test
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Enophthalmos◦
Inferior and Posterior Displacement of Globe and Intraorbital Soft Tissue◦
Etiology
Enlargement of the Bony Orbital CavityEscape of Orbital Fat or Fat NecrosisMuscle Entrapment in Fracture LineSoft Tissue Scarring and Contracture
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No Diplopia + No Enophthalmos?Significant Fracture
Diplopia + No EnophthalmosIncarceration Only
No Diplopia + EnophthalmosVolume Discrepancy Only
Diplopia + EnophthalmosIncarceration + Volume Discrepancy
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Symptomatic Diplopia With Positive Forced Duction TestXray evidence of Extraocular Muscle EntrapmentEarly Enophthalmos (>3mm)Large Orbital Floor DefectAbnormally Low Vertical Globe LevelAssociated Orbital Rim or Other Craniofacial Fractures
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Grafts◦
Autologous Bone◦
Cartilage◦
Fascia lata
Alloplastic Implants◦
Teflon◦
Silastic◦
Titanium
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InfectionImplant problemsPersistent Diplopia (2-50%)Persistent Enophthalmos (15-22%)Ectropion (1%)Blindness
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Superior Orbital Fissure Syndrome◦
extension of fracture into SOF◦
ophthalmoplegia with injury to III, IV or VI◦
anesthesia in V1 plus loss of corneal reflex◦
ptosis and proptosis◦
parasympathetic block
fixed, dilated pupil
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Orbital Apex Syndrome◦
same as superior orbital fissure syndrome◦
plus blindness