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Facial Fractures Lisa Publicover August 2005 Outline of Lecture • Introduction • Skeletal Anatomy • Fracture Patterns • • • • • • Nasal Zygomatic Maxilla Blowout Frontal Sinus and Nasoethmoidal Mandibular • Approach to a Suspected Facial Fracture Anatomy • The face is composed of 14 bones: 1. 2. 3. 4. 5. 6. 7. 8. Mandible (1) Vomer (1) Maxilla (2) Zygomata (2) Nasal (2) Lacrimals (2) Palatines (2) Inferior Nasal Conchae (2) Image from http://face-and-emotion.com/dataface/physiognomy/cranium.jsp 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 The Volmer • A small, narrow bone • Forms the inferior part of the nasal septum 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 The Zygomata • Paired • Form the “cheekbones” • Articulate with the temporal, frontal, and maxillary bones • Their prominent position and shape renders them susceptible to injury The Nasal Bones • Paired • Join in the midline to form the nasal bridge • They articulate with the frontal, maxillary, and ethmoid bones. The Lacrimal Bones • Paired • Small & Fragile • Located in the medial wall of each orbit • Contains a small fossa, which houses the lacrimal apparatus The Palatine Bones • Paired • Located posterior to the maxilla • Form the posterior part of the lateral wall of the nasal cavity The Inferior Nasal Conchae • Paired • Located within the nasal cavity • Project medially from the lateral walls of the nasal cavity Fracture Patterns • Nasal • Lateral Blow • Other • Zygomatic • Maxilla • LeFort I • LeFort II • LeFort III • Blowout • Frontal Sinus & Nasoethmoid • Mandibular Nasal Fractures I: Lateral Blow • Cause: Lateral force • Signs & Symptoms: • • • • • Pain Swelling Epistaxis Lacerations Respiratory Obstruction • Treatment: Emergency care, reduction & referral if presentation is delayed. Fracture Patterns • Nasal • Lateral Blow • Other • Zygomatic • Maxilla • LeFort I • LeFort II • LeFort III • Blowout • Frontal Sinus & Nasoethmoid • Mandibular Nasal Fractures II: Other • 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. Fracture Patterns • Nasal • Lateral Blow • Other • Zygomatic • Maxilla • LeFort I • LeFort II • LeFort III • Blowout • Frontal Sinus & Nasoethmoid • Mandibular 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 Fracture Patterns • Nasal • Lateral Blow • Other • Zygomatic • Maxilla • LeFort I • LeFort II • LeFort III • Blowout • Frontal Sinus & Nasoethmoid • Mandibular 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/facialfx.html 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 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. 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 Fracture Patterns • Nasal • Lateral Blow • Other • Zygomatic • Maxilla • LeFort I • LeFort II • LeFort III • Blowout • Frontal Sinus & Nasoethmoid • Mandibular 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 Fracture Patterns • Nasal • Lateral Blow • Other • Zygomatic • Maxilla • LeFort I • LeFort II • LeFort III • Blowout • Frontal Sinus & Nasoethmoid • Mandibular 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. Fracture Patterns • Nasal • Lateral Blow • Other • Zygomatic • Maxilla • LeFort I • LeFort II • LeFort III • Blowout • Frontal Sinus & Nasoethmoid • Mandibular 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 Mandibular Fractures (2) • Signs & Symptoms: • • • • • • • • Pain Malocclusion Excessive salivation Dysphagia Swelling Crepitation Discoloration Deformity Approach to a Suspected Fracture • • • • History Symptoms Physical Examination Imaging History • • • • • • • Cause of Fracture Degree of Force Specific Symptoms Time since injury Allergies Medications Etc. Physical Examination • Symmetry/Deformity • Lacerations/Abrasions/Ec chymoses • 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 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 References Grabb, W. & Smith,J. (1979). Plastic Surgery (3rd Ed.). Little, Brown and Company: Boston, MA University of Washington School of Medicine:http://www.rad.washington.edu/ mskbook/facialfx.html