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/fac
ialfx.html