FACIAL FRACTURESFACIAL FRACTURES

Jennifer R. DeckerJennifer R. DeckerDept of Otolaryngology Head & Neck Dept of Otolaryngology Head & Neck

SurgerySurgeryMcGaw / NMHMcGaw / NMH

Fracture TypesFracture Types Maxillofacial: Maxillofacial:

Buttresses & LeFort ClassificationButtresses & LeFort Classification FrontalFrontal ZMCZMC Orbital Wall & FloorOrbital Wall & Floor NOENOE

Mandibular:Mandibular: Favorable vs. unfavorableFavorable vs. unfavorable Symphyseal, parasymphyseal, body, angle,Symphyseal, parasymphyseal, body, angle, ramus, coronoidramus, coronoid Fixation optionsFixation options

Excluded: skull base & t-bone fracturesExcluded: skull base & t-bone fractures

LeFort I: low horizontal alveolar ridge traumLeFort I: low horizontal alveolar ridge traumaanasal aperture -> horizontal maxillanasal aperture -> horizontal maxillamaxillozygomatic jxn -> pterygomaxillary fissure & maxillozygomatic jxn -> pterygomaxillary fissure & pterygoid plates pterygoid plates

LeFort II: midmaxillary frontal blowLeFort II: midmaxillary frontal blownasal bridge -> lacrimal bone -> inf orbital floor /rimnasal bridge -> lacrimal bone -> inf orbital floor /rimant maxillary wall -> pterygomaxillary fissure -> platesant maxillary wall -> pterygomaxillary fissure -> plates

LeFort III: “craniofacial dissociation”LeFort III: “craniofacial dissociation”nasal bridge -> medial orbital wall -> orbital floor -> lateral nasal bridge -> medial orbital wall -> orbital floor -> lateral

orbital wall -> zygomaticofrontal jxn & zygomatic arch orbital wall -> zygomaticofrontal jxn & zygomatic arch

Frontal Sinus FracturesFrontal Sinus Fractures 5-15% of Midface fx5-15% of Midface fx Requires 800-2200 pounds of forceRequires 800-2200 pounds of force Anterior Table: Anterior Table:

Contours forehead Contours forehead Contributes to frontal horizontal buttressContributes to frontal horizontal buttress

Posterior Table:Posterior Table: Less common fractureLess common fracture Risk of CSF leak, infectionRisk of CSF leak, infection

Frontal Floor: (orbital roof)Frontal Floor: (orbital roof) houses nasofrontal duct houses nasofrontal duct

Frontal Fracture: QuestionsFrontal Fracture: Questions

Anterior table, posterior table or both?Anterior table, posterior table or both? Displacement or comminution?Displacement or comminution? Nasofrontal duct involvement (orbital Nasofrontal duct involvement (orbital

roof)?roof)? Pneumocephalus or suspected dural Pneumocephalus or suspected dural

involvement? involvement? Associated brain injury?Associated brain injury?

Frontal Fx ManagementFrontal Fx Management

Anterior:Anterior: Non-displaced: observeNon-displaced: observe Displaced: repair cosmetic deformityDisplaced: repair cosmetic deformity

Posterior:Posterior: Non-displaced: closely observed, repeat CTsNon-displaced: closely observed, repeat CTs Comminuted or displaced: usually exploreComminuted or displaced: usually explore

Sinus obliteration (mild) or cranialization (severe)Sinus obliteration (mild) or cranialization (severe)

Nasofrontal duct involvement:Nasofrontal duct involvement: Floor of sinus + NOE fxFloor of sinus + NOE fx Explore: Lothrop vs obliterationExplore: Lothrop vs obliteration

Frontal sinus Frontal sinus fracturesfractures

Posterior Fracture & CranializationPosterior Fracture & Cranialization

Zygomatico-maxillary complexZygomatico-maxillary complex

Direct blow to malar eminenceDirect blow to malar eminence Articulates with: maxillary, temporal, Articulates with: maxillary, temporal,

frontal, and sphenoid bonesfrontal, and sphenoid bones Five radiologic fracture sitesFive radiologic fracture sites

1.1. Lateral orbital wallLateral orbital wall

2.2. Anterior maxillary wallAnterior maxillary wall

3.3. Lateral maxillary wallLateral maxillary wall

4.4. Zygomatic archZygomatic arch

5.5. Orbital floorOrbital floor

ZMC: fracture of three sutures lines ZMC: fracture of three sutures lines surrounding the malar eminence give surrounding the malar eminence give

the nickname “tripod” the nickname “tripod”

ZMC Arch Fractures ZMC Arch Fractures Posterior, Rotated: inward vs outward, AngulatedPosterior, Rotated: inward vs outward, Angulated

ZMC Questions:ZMC Questions:

Displaced vs non-displaced?Displaced vs non-displaced? Comminuted? Comminuted? Other fractures? (high-energy blow)Other fractures? (high-energy blow)

““Tripod”, hemi-LeFort, orbital floor?Tripod”, hemi-LeFort, orbital floor? Orbital volume loss?Orbital volume loss?

> 50% volume loss = repair> 50% volume loss = repair Status of orbital apex?Status of orbital apex?

Close to carotids, CN II (optic foramen), Close to carotids, CN II (optic foramen), CN III, IV, V1, VI (superior orbital fissure)CN III, IV, V1, VI (superior orbital fissure)

ZMC RepairZMC Repair Arch: depressed = repair (Giles, direct)Arch: depressed = repair (Giles, direct) rotated = platingrotated = plating minimal displacement = soft dietminimal displacement = soft diet Tripod: non-comminutedTripod: non-comminuted

Gingivobuccal & blepheroplasty incisionsGingivobuccal & blepheroplasty incisions Visualize reduction of ZM, ZF, ZT fx; feel ZS reductionVisualize reduction of ZM, ZF, ZT fx; feel ZS reduction

Tripod: comminutedTripod: comminuted Align other NOE or orbital fractures as wellAlign other NOE or orbital fractures as well

Orbital wall fractures:Orbital wall fractures: Repair for > 50% volume loss or entrapmentRepair for > 50% volume loss or entrapment

Orbital Wall & Floor FracturesOrbital Wall & Floor Fractures

Orbital Rim fracturesOrbital Rim fractures Often in conjunction with ZMC or zygomatic Often in conjunction with ZMC or zygomatic

fracturesfractures

Orbital “blowout” fracturesOrbital “blowout” fractures Includes isolated wall, floor, or roof fracturesIncludes isolated wall, floor, or roof fractures Force is transmitted through the globe to the Force is transmitted through the globe to the

delicate wallsdelicate walls Always needs an ophtho consult!Always needs an ophtho consult!

Orbital BlowoutOrbital Blowout

Surgical indications: Orbital Wall FxSurgical indications: Orbital Wall Fx

Multiple fractures with loss of volumeMultiple fractures with loss of volume EntrapmentEntrapment Globe malposition: prevent enopthalmosGlobe malposition: prevent enopthalmos Lateral orbital wall projects into obital apex Lateral orbital wall projects into obital apex

or middle cranial fossaor middle cranial fossa

Orbital Floor Orbital Floor “Trap Door”“Trap Door”

Orbital volume lossOrbital volume loss

High-Impact orbital fractureHigh-Impact orbital fracture

Orbital Wall Questions:Orbital Wall Questions:

Is there enophthalmos?Is there enophthalmos? Is there entrapementIs there entrapement

Surgical urgencySurgical urgency

Are other orbital walls fractured?Are other orbital walls fractured? Rim fractures: are there ZMC or NOE Fx?Rim fractures: are there ZMC or NOE Fx? Ask radiology to estimate percentage of Ask radiology to estimate percentage of

walls / floor involvedwalls / floor involved

Naso-Orbital-Ethmoid FracturesNaso-Orbital-Ethmoid Fractures

Low-force to nose = nasal bone fxLow-force to nose = nasal bone fx High-force to nose = add maxilla & ethmoidsHigh-force to nose = add maxilla & ethmoids ““Crumple zone” protects brain / orbital apexCrumple zone” protects brain / orbital apex Significant cosmetic deformitySignificant cosmetic deformity Medial canthal tendon injuryMedial canthal tendon injury

Inserts on anterior & posterior surfaces of anterior Inserts on anterior & posterior surfaces of anterior lacrimal crest + frontal process of maxillalacrimal crest + frontal process of maxilla

Results in telecanthusResults in telecanthus

Epiphora: Epiphora: Drainage: medial puncta -> canaliculi -> nasolacrimal Drainage: medial puncta -> canaliculi -> nasolacrimal

sac -> nasolacrimal ductsac -> nasolacrimal duct

Markowitz ClassificationMarkowitz ClassificationType 1: attached tendonType 1: attached tendonType 2: comminuted, Type 2: comminuted, attached tendonattached tendonType 3: comminuted, Type 3: comminuted, detached tendondetached tendon

Mandible FracturesMandible Fractures

Mandible ForcesMandible Forces

Fracture ManagementFracture Management

Favorable fractures: Favorable fractures: MMF x 4-6 weeks for ramus, body & condyle MMF x 4-6 weeks for ramus, body & condyle

Unfavorable fractures:Unfavorable fractures: Combination of MMF & ORIFCombination of MMF & ORIF If have 2 plates per fracture, may remove MMFIf have 2 plates per fracture, may remove MMF Symphyseal & parasymphyseal: mono & Symphyseal & parasymphyseal: mono &

bicortical screwsbicortical screws Ramus: 2 bicortical plates or MMFRamus: 2 bicortical plates or MMF Lag screws: no commonly used at NMHLag screws: no commonly used at NMH

Complications & EmergenciesComplications & Emergencies

Infection, malocclusion, non-unionInfection, malocclusion, non-union TMF ankylosis / dysfunctionTMF ankylosis / dysfunction Inf alveolar N damageInf alveolar N damage

Airway ObstructionAirway Obstruction Condyle in middle fossaCondyle in middle fossa HemorrhageHemorrhage

Non-emergentNon-emergent Non-emergent Non or minimally displaced nasal Non-emergent Non or minimally displaced nasal

bonebone Anterior maxillary wallAnterior maxillary wall Lamina Papyracea w/o entrapmentLamina Papyracea w/o entrapment Orbital floor w/o volume loss or entrapmentOrbital floor w/o volume loss or entrapment

PearlsPearls All fractures need antibioticsAll fractures need antibiotics All mandible fractures except coronoid and All mandible fractures except coronoid and

some condylar need MMF &/ or ORIFsome condylar need MMF &/ or ORIF All open mandible fracture need IV abxAll open mandible fracture need IV abx Document sensation (V1-3 & inf alveolar n)Document sensation (V1-3 & inf alveolar n) All midface fx should avoid nose-blowingAll midface fx should avoid nose-blowing