Otolaryngol Clin N Am

41 (2008) 5176

Facial Fractures: Beyond Le Fort

Rebecca E. Fraioli, MDa,
Barton F. Branstetter IV, MDa,b,
Frederic W.-B. Deleyiannis, MD, MPhil, MPHa,c,*
a
Department of Otolaryngology, University of Pittsburgh Medical Center,
Eye and Ear Institute, 203 Lothrop Street, Suite 500, Pittsburgh, PA 15213, USA
b
Department of Radiology, University of Pittsburgh Medical Center,
200 Lothrop Street, Pittsburgh, PA 15213, USA
c
Division of Plastic Surgery, Departments of Surgery and Otolaryngology,
University of Pittsburgh Medical Center, 6B Scaife Hall, 3550 Terrace Street,
Pittsburgh, PA 15261, USA

The management of facial fractures begins with the establishment of an

accurate fracture diagnosis. All too often, radiology reports contain a laundry list of fractures without clinical context, without an understanding of
fracture patterns, or without categorization by fracture severity, fracture
criticality, or the need for surgical repair. For example, a radiology report
that focuses on nasal septal fractures, but ignores a medial canthal avulsion,
can be annoying or even misleading to the surgeon.
Fracture complexes are reproducible, and the terminology of fracture
complexes allows for ecient communication between physicians of intricate fracture patterns in the midface. This type of communication requires
that the radiologist understand common mechanisms of injury and the fracture complexes that result.
The best-known categorization scheme for fracture fractures is that of
Rene Le Fort. However, Le Forts work was based on low-speed impact,
and does not completely reect the breadth of trauma that is encountered
in modern medicine. The purpose of this issue is to provide a broader classication scheme for midface fracture complexes, which incorporates, and
yet goes beyond, Le Forts classication. The goal is to encourage more clinically relevant radiology reports, so that surgeons will know what to expect,
and radiologists will know what to provide, in the CT evaluation of facial
* Corresponding author. Division of Plastic Surgery, Departments of Surgery and
Otolaryngology, University of Pittsburgh Medical Center, 6B Scaife Hall, 3550 Terrace
Street, Pittsburgh, PA 15261.
E-mail address: deleyiannisfw@msx.upmc.edu (F.W.-B. Deleyiannis).
0030-6665/08/$ - see front matter 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2007.10.003

oto.theclinics.com

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fractures. Variables that aect surgical management will be emphasized. At

the end of each section, there is a short list of pearls for creating clinically
relevant radiology reports.
This issue is focused on midface fractures; mandibular and skull base
fractures are intentionally excluded to retain this focus.

Frontal sinus fractures

Fractures of the frontal sinuses comprise about 5% to 15% of maxillofacial fractures [13]. These fractures are generally classied by involvement of
the anterior wall (anterior table) or posterior wall (posterior table). In addition, fractures of either wall may be comminuted or noncomminuted, and
displaced or nondisplaced. Finally, involvement of either the nasofrontal
duct or the anterior cranial fossa dura has important implications for the
clinical management of these fractures.
The importance of the radiologic diagnosis of frontal sinus fractures is
underscored by the fact that before the advent of routine CT scanning for
head trauma, 50% of frontal sinus fractures were not identied until after
the patient had left the emergency room [4]. The frontal bone is the strongest
of the facial bones, and a large amount of force (800 to 2200 lb) is required
to fracture the frontal sinuses [5]. The presence of frontal sinus fractures
may therefore be considered an indicator of a high-force injury, and should
alert the physician to search for other injuries. Additional craniofacial
injuries are present in 56% to 87% of patients with frontal sinus fractures
[4,611]. An associated cerebrospinal uid (CSF) leak is present in 13%
to 33% of patients with frontal sinus fractures [4,6,8,10,12]. Mortality secondary to other associated injuries has been reported at rates of approximately 9% of patients with frontal sinus fractures [6].
Structures involved
Each wall of the frontal sinus serves a dual function. The anterior wall of
the frontal sinus, formed by the frontal bone, is responsible for the aesthetic
contours of the forehead and the superior orbital rims. In addition, this
structure serves as the frontal bar, one of the key horizontal buttresses of
the facial skeleton (Fig. 1). The frontal bar helps to maintain the horizontal
dimension of the face and to provide a stable foundation for the vertically
oriented facial buttresses (see Fig. 1) that support the forces of mastication.
Fractures of the anterior table may be clinically important either by disrupting the aesthetic contour of the forehead or by destabilizing the frontal bar
from which the other facial bones are suspended [13]. The posterior wall of
the frontal sinus forms the anterior wall of the anterior cranial fossa, and
serves to separate the sinus contents from the cranial vault. Posterior table
fractures are therefore skull fractures, and must be recognized and managed
as such. The oor of the frontal sinus forms the medial orbital roof; it also

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Fig. 1. The buttress system of the midface. The buttress system of the midface is formed by the
strong frontal, maxillary, zygomatic, and sphenoid bones and their attachments to one another.
The central midface consists of several fragile bones that easily crumple when subjected to
strong forces. These more fragile bones are surrounded by the thicker bones of the buttress
system, which provide structure and absorb the forces applied to the face. Most of the forces
absorbed by the face are masticatory, therefore the vertical buttresses are the most well developed. These include the medial nasomaxillary buttress and the lateral zygomaticomaxillary buttress. Three horizontal buttresses interconnect and provide support for the vertical buttresses:
the frontal bone and supraorbital rims (frontal bar), the nasal bones and inferior orbital
rims, and the maxillary alveolus. (From Linnau KF, Stanley RB Jr, Hallam DK, et al. Imaging
of high-energy midfacial trauma: what the surgeon needs to know. Eur J Radiol 2003;48:1732;
with permission.)

houses the ostium to the nasofrontal duct in its posteromedial aspect [9].
The nasofrontal duct forms the drainage pathway of the frontal sinus into
the nose, so obstruction of this pathway can lead to mucocele, mucopyocele,
osteomyelitis, and epidural or subdural abscess [12].
Variables aecting treatment
There are three main variables to consider when assessing the need for
surgical intervention for frontal sinus fractures. These are involvement of
the anterior table, disruption of the nasofrontal duct, and involvement of
the posterior table. When assessing the involvement of the anterior or posterior tables, the degree of fracture displacement and comminution are also
important. An additional factor involved when assessing the posterior table
is the likelihood of dural penetration or nasofrontal duct disruption.

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Anterior table fractures

Nondisplaced anterior table fractures require no surgical intervention.
Displaced anterior table fractures may cause cosmetic deformity because
of facial stepos, asymmetry, or attening of the normally convex glabella.
Repair of these defects is ideally performed within 10 days of the injury,
a time during which soft tissue edema resulting from the trauma may mask
the cosmetic deformity. Consequently, radiologic estimates of the degree of
displacement of the anterior table and the resultant cosmetic deformity are
critical in making the determination of whether to proceed with surgery.
Posterior table fractures
The management of posterior table fractures remains somewhat controversial. Nondisplaced posterior table fractures are frequently treated conservatively with close follow-up [2,11]. Follow-up should include early and
repeated CT scans of the sinuses [3,11]. In contrast, comminuted or
displaced posterior table fractures are generally felt to increase the risk of
complications and thus merit exploration [3,14]. The presence of pneumocephalus, although not specic, may indicate dural violation, and also may be
an indication for surgical exploration of the fracture [14]. Posterior table
fractures may be managed with sinus obliteration if the oor of the sinus
is not comminuted and there is not a large amount of bone missing
(Fig. 2). Severely comminuted or displaced posterior wall fractures frequently require cranialization (Fig. 3) [6,14,15].
Involvement of the nasofrontal duct
If the nasofrontal duct is disrupted, operative intervention is necessary.
A few recent reports suggest that conservative management with an endoscopic Lothrop procedure when necessary to reestablish the frontal sinus
drainage pathway may be an option; however, the most trusted method
of management is to obliterate the sinus and nasofrontal duct ostium
[11,1619]. Disruption of the nasofrontal duct may be dicult to assess
on CT, and intraoperative exploration is often necessary to make the nal
determination of future nonfunction of the duct. However, the CT report
should indicate the likelihood of duct disruption based on the location
and degree of displacement of the fracture. Nasofrontal duct disruption is
most likely in cases where there is a displaced anterior table fracture medial
to the supraorbital notch and involving either the oor of the frontal sinus,
the naso-orbital-ethmoidal (NOE) complex (see Naso-orbital-ethmoidal
(NOE) fractures), or both [16].
Clinically relevant radiology reports: Frontal sinuses
1. Indicate whether the fracture involves the anterior wall, posterior wall,
or both, as well as the degree of displacement and comminution of the
fracture.

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Fig. 2. Frontal sinus obliteration. (A) Axial CT scan demonstrates fractures of both anterior
(arrowheads) and posterior (arrow) tables of the frontal sinuses. At exploration, the dura was
found to be intact and there was no evidence of CSF leak, therefore cranialization was not
performed. However, the presence of an associated severe NOE fracture suggested disruption
of the nasofrontal ducts bilaterally, and therefore the sinuses were obliterated bilaterally with
concominant plugging of the nasofrontal ducts with calvarial bone grafts (CBGs) and free pericranium. (B) Postoperative axial CT scan showing reduction of the posterior table with xation
of the anterior table fractures. (C) Coronal CT scan demonstrating the CBGs used to plug the
nasofrontal ducts (wide arrows). Additional CBGs were required in this patient to reconstruct
the oor, medial wall, and roof of the left orbit (thin black arrows).

2. For posterior wall fractures, indicate the presence or absence of pneumocephalus with an estimation of the likelihood of dural violation
and the degree of bone loss in the posterior wall and oor of the sinus.
3. Indicate the likelihood of nasofrontal duct obstruction based on the
fracture location.
4. Comment on any associated brain injury. This is especially important
for posterior table fractures.
Zygomatico-maxillary complex (ZMC) fractures
The malar eminence of the zygoma is the most anterior projection of the
lateral face. This prominent position makes the zygoma susceptible to trauma;

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Fig. 3. Frontal sinus cranialization. This patient was involved in a high-velocity motor vehicle
collision that resulted in combined anterior and posterior sinus fractures with displacement of
the posterior table, dura injury, and frontal contusion. Frontal sinus cranialization was performed using an anteriorly based pericranial ap and CBGs to plug the nasofrontal ducts.
The anterior table fractures were managed with open reduction and xation. (A) Preoperative
axial CT scan demonstrating anterior and posterior table fractures and associated pneumocephalus (arrow). (B) Postoperative axial CT scan demonstrating cranialization (note the absence
of the posterior table). (C) Postoperative sagital CT scan demonstrating cranialization. The
arrow indicates the window made in the frontal bone to allow intracranial passage of the pericranial ap. The pericranial ap was draped over the anterior skull base to reinforce the dura.

one study demonstrated zygomatic complex fractures to be the most common

type of facial fracture in patients admitted to the hospital following blunt
facial trauma [20]. The central portion of the zygomatic bone is sturdy, and
contributes to the vertical buttress system of the midface (see Fig. 1); however,
the projections of the zygoma by which it articulates with the surrounding
facial bones, and the articulating bones themselves, are weaker. This often
results in fracture of the zygoma at its suture lines, classically labeled as a tripod fracture in reference to the three anterior suture lines that are fractured:
the zygomaticfrontal (ZF), zygomaticotemporal (ZT), and zygomaticomaxillary (ZM) sutures (Fig. 4). However, the zygoma has a fourth articulation site
with the sphenoid bone, which is also fractured, and radiographically, ve distinct fractures are demonstrated (lateral orbital wall, orbital oor, anterior

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Fig. 4. Traditional ZMC fracture. (A) Three-dimensional (3D) surface rendering demonstrates
disruption of the three suture lines surrounding the malar eminence: the zygomaticofrontal
suture (white arrow), the zygomaticomaxiallry suture (black arrow), and the zygomaticotemporal suture (arrowhead). These three sutural disruptions lend the ZMC fracture its nickname,
tripod fracture. Note the associated NOE fracture (*). (B) Coronal CT scan showing
fractures of the lateral orbital wall (straight arrow), orbital oor (curved arrow), and zygomaticomaxiallary suture (arrowhead). (C) Axial CT demonstrating medial displacement of a bone
fragment (arrow) from the lateral orbital wall toward the globe. (D) Postoperative CT scan
following removal of the bone fragment and reconstruction of the lateral orbital wall with
a relatively radiolucent Lactosorb bioabsorbable plate (arrows). The NOE fracture (arrowhead)
has been incompletely reduced.

maxillary wall, lateral maxillary wall, and zygomatic arch). Thus, the name
tripod fracture is technically inaccurate. A more compelling reason to avoid
the term tripod fracture is because it fails to recognize that this fracture
complex is intermediate on a spectrum of injuries that range from an isolated,
nondisplaced fracture limited to the zygomatic arch to severe displacement
and comminution of the zygoma and surrounding bones. This spectrum of
fractures all have similar mechanisms of injury, but dier in the amount of

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force applied and therefore in the degree of bone loss and displacement [20].
For this reason, it is preferable to classify this entire spectrum of fractures
together as zygomaticomaxillary complex (ZMC) fractures.
Structures involved
The zygoma is an approximately quadrilateral-shaped bone. The body of
the zygoma forms the malar prominence, which is an important aesthetic
feature of the face. A prominent malar eminence has been described as a
sign of youth and beauty [21]. Through its attachments to the surrounding
facial bones, the zygoma also helps to determine midfacial height and width
[22]. From the laterally oriented malar prominence, the zygoma sends four
projections that articulate with the surrounding facial bones. Superiorly, the
zygoma articulates with the frontal bone at the narrow frontozygomatic
suture; medially, it has a wider articulation with the maxilla, involving
both the anterior and lateral walls of the antrum. The curved bony strut
of the zygoma lying between these superior and medial projections forms
the lateral orbital wall and the lateral aspect of the infraorbital rim and
orbital oor. Posteriorly, the zygoma articulates with the sphenoid bone,
and laterally it extends as the zygomatic arch to attach to the temporal
bone at the zygomaticotemporal suture.
The presence of the thick bone of the zygoma at the lateral corner of the
midface allows it to act as a cornerstone to provide support to the other
facial bones [23]. The maxilla directly contacts the frontal bone at the frontomaxillary suture line and the sphenoid bone posteriorly above the maxillary tuberosity and anterior to the sphenopalatine foramen. The zygoma
then overlies and reinforces this area through its attachments to the underlying frontal, maxillary, sphenoid, and temporal bones.
Variables aecting treatment
The goal of reconstruction in ZMC fractures is to restore the height,
width, and projection of the malar eminence. The degree of fracture displacement and comminution determines the extent of the surgical exposure
needed for repair. Nondisplaced and minimally displaced fractures frequently do not require surgical intervention [20]. Displaced and comminuted
fractures generally require open reduction and xation. The rst and most
critical step in management of ZMC fractures is achieving adequate reduction [24]. When fractures are not signicantly comminuted, as is the case in
a classic tripod fracture, the entire zygoma may be reduced as a single unit.
In such cases, ZMC fractures may be managed through the use of limited
incisions, in particular an upper gingivobuccal (UGB) incision and a lateral
upper blepheroplasty (LUB) incision. Reduction can, in these cases, be
accurately assessed by conrming reduction at the ZM suture (through
the UGB incision), the ZF suture (through the LUB incision), and the ZS
suture (through the LUB incision).

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Accurate depiction of ZMC fracture displacement can be accomplished

with CT (Fig. 5). The malar eminence is often displaced posteriorly, but
the degree of displacement may be masked clinically by soft tissue swelling
(see Fig. 5A). The malar eminence may be rotated internally or externally
(see Fig. 5B, C). Occasionally, the zygomatic arch fracture that accompanies
ZMC fractures will not be evident radiographically as a discrete linear
hypodensity. Abnormal curvature of the zygomatic arch should be considered equivalent to a discrete fracture in this setting (see Fig. 5D).
Accurate reduction is more dicult to assess in comminuted fractures.
When the zygoma itself is comminuted, it cannot be reduced as a single
unit, and accurate reduction at one suture line does not imply adequate

Fig. 5. ZMC variants. (A) Axial CT shows posterior displacement of the ZMC (double arrow).
This displacement would be masked clinically by soft tissue swelling (note symmetry of facial
soft tissues). (B) Internal rotation (arrow) of a ZMC fracture. Note the increased interzygomatic
distance. (C) External rotation (arrow) of a ZMC fracture. Note the decreased interzygomatic
distance. (D) Zygomatic arch angulation. Although no discrete fracture line is seen through the
arch, it is abnormally angulated (arrow), which is sucient for the diagnosis of ZMC fracture.

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reduction at the others. In such cases, additional incisions may be necessary

for fracture reduction and xation. Eyelid incisions (ie, transconjunctival
incision with a lateral canthotomy or subciliary incision) provide exposure
to the orbital rim. A coronal access incision may be necessary for wider
exposure of the zygomatico-sphenoid suture line, lateral orbit, and zygomatic arch. In addition, the high-energy trauma required to create comminuted zygoma fractures frequently also results in comminuted fractures of
the surrounding bones. Le Fort, NOE, and panfacial fractures frequently
coexist with ZMC fractures [20]. Identication of these coexisting fractures
is critical for determining accurate reduction of the ZMC. Failure to recognize coexisting fractures may mislead the surgeon into aligning the ZMC
with another segment of the buttress system that is itself displaced; this in
turn may result in postoperative cosmetic deformity [24].
Another major variable aecting the surgical management of ZMC fractures is the status of the orbital oor. The zygoma contributes to both the
lateral and the inferior orbital walls. Displacement of these walls frequently
occurs in ZMC fractures, and may result in an increased volume of the bony
orbit. This increase in orbital volume is the most common cause of posttraumatic enophthalmos [25]. Restoration of the pretrauma orbital volume is
therefore a primary goal of ZMC fracture management. Before the advent
of routine CT scanning for these injuries, the decision of whether or not
to explore the orbit was made on a clinical basis. CT scan has been shown
to be a reliable method of making the decision of which orbits require exploration [24,26,27]. The ability to make this determination based on the CT
scan allows those patients without signicant orbital volume expansion to
be spared the morbidity of a subcilliary or transconjunctival incision.
Some degree of ectropion and scleral show may complicate as many as 20%
of these incisions [28]. Radiologic criteria suggesting the need for orbital
exploration include severe comminution or displacement of the orbital
rim, displacement of greater than 50% of the orbital oor with prolapse
of the orbital contents into the maxillary sinus, an orbital oor fracture
greater than 2 cm2, and the combination of an inferior and medial wall
fracture [26,28]. Based on these or similar criteria, approximately 30% to
44% of patients with ZMC fractures require an orbital incision [24,26].
A nal variable to consider in ZMC fractures is the status of the orbital
apex. The orbital apex is the posterior portion of the orbit that contains the
optic nerve and lies in close apposition to the internal carotid arteries and
cavernous sinuses. Injury to this area may result in a number of serious
injuries resulting from injury to the carotid arteries and to cranial nerves
II, III, IV, V1, and VI [29]. The lateral wall of the orbital apex is formed
by the greater wing of the sphenoid. This bone also contributes to the lateral
orbital wall and articulates anteriorly with the zygoma. ZMC fractures may
result in displacement of the greater wing of the sphenoid [29]. It is important to note whether this displacement occurs laterally or medially (into the
orbital apex). The medial wall of the orbital apex is formed by contributions

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from the ethmoid and palatine bones and the body of the sphenoid bone.
Fractures in these areas should also alert the radiologist to possible orbital
apex involvement.
Clinically relevant radiology reports: ZMC fractures
1. Recognize that a range of injuries from an isolated zygomatic arch fracture, to a classic tripod fracture, to a displaced, comminuted zygoma all
represent fractures of the zygomaticomaxillary complex (ZMC).
2. Comment on the degree of displacement and comminution of the ZMC
fracture. The more displaced and the more comminuted the involved
bones are, the more complex the surgical repair with a need for wider
surgical exposure and more points of xation.
3. Comment on the extent of orbital involvement. Fractures involving
more than 50% of the orbital oor will likely require open
reconstruction.
4. Identify whether the medial orbital wall (lamina papyracea) is involved.
An isolated medial orbital wall fracture is generally not a cause of clinically signicant orbital volume loss; however, when found in combination with a oor fracture, it may require repair.
5. Comment on the involvement of the orbital apex and the direction of
displacement of the lateral orbital wall.
Nasal-orbital-ethmoid (NOE) fractures
The nasal bones lie in close apposition to the ethmoid sinuses and the
medial orbital walls. Low-force nasal trauma often remains limited to the
nose, resulting in isolated nasal bone fractures. By contrast, high-force
trauma is often transmitted through the nasal bones to also involve the
underlying ethmoid sinuses and orbit [30]. Because of the intimate physical
and functional relationship of the bony structures in this area, it is useful to
consider the nasal-orbital-ethmoid region as a single unit when dealing with
high-velocity facial trauma.
Structures involved
The nasal bones articulate superiorly with the nasal process of the frontal
bone, laterally with the frontal process of the maxilla, and medially with one
another. Just deep to the nasal bones lie the thin bones and air spaces of the
ethmoid sinuses. The lateral boundary of the ethmoid sinuses is the medial
orbital wall, which is formed by contributions from the frontal process of
the maxilla as well as the lacrimal, frontal, ethmoid, sphenoid, and palatal
bones [31]. As discussed in the preceding paragraph, high-velocity trauma
to this area is generally transmitted to involve all of these bones to varying
degrees. Evolutionarily, there is great advantage to the design of these thin
bones and air-lled spaces: they form a low-resistance crumple zone that

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allows the traumatic force to be dissipated. The critical structures such as

the brain and optic nerve lie within stronger bone behind this crumple
zone and are thus relatively protected from injury [32].
Despite the protective nature of this design, signicant cosmetic and
functional decits may arise from high-force NOE injury. Midface retrusion
and nasal shortening occur as a result of the nasal bones telescoping
inwards into the crumple zone. The medial canthal tendon (MCT) inserts
on the anterior and posterior lacrimal crests and the frontal process of
the maxilla. Telecanthus arises from displacement of the MCT fragment
or disruption of the MCT from its bony insertions. Epiphora is another frequent complication of fractures in this area. The lacrimal drainage pathway
extends from the lacrimal puncta at the medial canthus through the canaliculi, nasolacrimal sac, and nasolacrimal duct. These structures are closely
related to the lacrimal and maxillary bones as well as to the medial canthal
tendon; disruption of any of these related structures places the lacrimal
drainage pathway in danger of obstruction [30,3335]. Persistent posttraumatic epiphora has been reported in 5% to 31% of patients with NOE fractures [35]. Damage may also occur to the frontonasal duct (see Frontal
sinus fractures).
Variables aecting treatment
Status of the medial canthal tendon
Markowitz and colleagues [36] classied NOE fractures based on the status of the medial canthal tendon and the degree of comminution of the fragment of bone to which it remains attached (Fig. 6). Type I injury occurs
when fracture lines leave a central segment of bone with the medial canthal
tendon attached (Fig. 7). These are the simplest to reconstruct, as this central segment can be plated to the surrounding facial bones. Type II fractures
involve comminution of the central fragment, but the MCT remains rmly
attached to a denable segment of bone. Type III fractures result in severe
central fragment comminution with disruption of the MCT insertion sites.
Type II and III injuries are the most dicult to repair, and require transnasal wiring (Fig. 8) of the medial canthal tendon-bearing bone fragments
(Type II) or the MCT (Type III). Clinically, identication of these injuries
is often dicult because of the presence of soft tissue edema. Thus, it is critically important to identify displacement or comminution of the medial canthal tendon insertion radiographically.
Degree of bony injury: comminution and posterior displacement
In addition to the degree of comminution of the central fragment, the
degree of comminution of the surrounding nasal, maxillary, and orbital
walls also plays an important role in the reconstructive plan. Severe comminution, posterior displacement, or loss of bone in the midface precludes
reconstruction with plates and screws alone, and serves as an indication to

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Fig. 6. NOE fractures: Markowitz classication. (A) Type I fracture. The central fragment is
large enough to allow direct plating of the fragment with attached bone. (B) Type II fracture.
The central fragment is more comminuted that in Type I, but the MCT remains attached to the
central fragment. (C) Type III fractures involve severe comminution of the central fragment
with avulsion of the MCT. (From Markowitz BL, Manson PN, Sargent L, et al. Management
of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central
fragment in classication and treatment. Plast Reconstr Surg 1991;87(5):84353; with
permission.)

the surgeon that bone grafting will be necessary to reestablish adequate

facial projection. Bone grafting is frequently necessary following NOE
fractures to restore orbital volume and nasal projection (see Fig. 7)
[36,37].

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Fig. 7. Markowitz Type I NOE fracture. (A) A 3D surface-rendered CT scan showing large noncomminuted central fragment (arrow). (B) Postoperative sagital CT scan showing cantilevered
bone graft (arrow) in place to restore nasal projection. (C) Postoperative 3D surface rendering
demonstrates plating of the central fragment (thin arrow) and cantilevered bone graft (thick arrow).

Associated injuries
The cribiform plate forms the roof of the nasal cavity; as such, it is at risk for
involvement in cases of NOE fracture. The nasofrontal duct may also be injured at the site of its outow in the anterior ethmoid sinuses. Finally, NOE
fractures are associated with high-force trauma involving the medial orbital
wall and have been associated with several ocular injuries, including hyphema,
vitreous hemorrhage, lens dislocation, and globe rupture [30]. These associated injuries should be sought and commented upon in the radiology report.
Clinically relevant radiology reports: NOE fractures
1. Recognize that a nasal bone fracture in combination with a fracture of
the medial orbital wall and frontal process of the maxilla represents

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Fig. 8. NOE fracture and repair. (A) Axial CT through the NOE shows a left Type II (small
fracture fragment, but still attached to the canthal ligament) fracture (arrow). (B) Postoperative
frontal radiograph shows a cerclage wire (arrows) attached to both NOE fragments to hold
them into position.

2.

3.

4.

5.

disruption of a facial unit known as the nasal-orbital-ethmoid (NOE)

complex.
Indicate whether the central fragment of the medial orbital wall (to
which the medial canthal tendon attaches) is displaced and/or
comminuted.
Comment on the degree of displacement of the nasal root (nasal bridge),
either posteriorly into the ethmoids or superiorly into the anterior cranial fossa.
Comment on the degree of comminution of the nasal bones, frontal processes of the maxilla, and nasal processes of the frontal bones, as comminution in these areas may require the surgeon to plan for bone grafting.
Comment on the presence or absence of commonly associated injuries,
including cribiform plate fracture, nasofrontal duct injury, and ocular
injury.

Orbital wall and oor fractures

There are two main types of orbital fractures. The rst type occurs when
one or more of the bony walls of the orbit are fractured. The inferior orbital
rim, in particular, is frequently fractured and displaced inward into the
orbit. The displaced bone directly impacts the more delicate bones of the
orbital walls and orbital oor, resulting in secondary fractures in these
regions. Because the inferior orbital rim is derived largely from the zygomatic bone, fractures of the zygoma or its attachments that result in displacement of the zygoma frequently cause secondary fractures of the
orbital walls and oor [38]. The second type of orbital fracture is what is

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commonly known as an orbital blowout fracture. In this type of fracture,

the orbital rim remains intact, but the force of impact is transmitted to the
delicate bones of the orbital oor, roof, and medial wall (Fig. 9), causing
fractures in these bones without disrupting the continuity of the stronger
inferior, lateral, and superior orbital rims.
Structures involved
The orbit is shaped like a cone, with the apex posteriorly. The greatest
diameter is not at the inferior orbital rim, however, but approximately 15
mm posterior to it, at a point where the medial wall, roof, and oor of
the orbit are all concave relative to each other [39]. Posterior and posteromedially to this, the orbital oor becomes convex. This conguration has
important implications for reconstruction of orbital fractures, as failure to
reconstruct the convex portion (including the medial orbital wall) is one
of the common causes of postoperative enophthalmos [40].
Variables aecting treatment
The primary determination to make when assessing the CT scan is
whether the orbital fracture is an isolated blowout fracture or part of a larger
fracture pattern. Orbital fractures occur in combination not only with ZMC
fractures but also with Le Fort and NOE fractures. If the orbital fractures
consist only of fractures of the orbital oor, roof, or medial wall without
fracture of the rm orbital rims, then the treatment algorithm for orbital
blowout fractures applies. Orbital fractures occurring along with other fracture patterns are more likely to be the result of a high-force injury, and frequently require a more extensive surgical repair.

Fig. 9. Orbital blowout fractures. Although orbital oor fractures (arrow, A and B) are the
most common type of blowout fracture, medial wall fractures (arrowheads, A) and superior
wall fractures (arrow, B) may also be seen.

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There are three main indications to treat isolated orbital wall fractures.
The rst is entrapment of any of the extraocular muscles. Entrapment of
the muscle can cause ischemic damage, and permanent dysfunction can
occur if the fracture is not reduced and the muscle released expeditiously
[41,42]. Entrapment is diagnosed on clinical exam and cannot be directly
assessed on CT. However, herniation of the extraocular muscles beyond
the bony margins of the orbit is suggestive of entrapment and should be
sought on CT. The radiologic diagnosis of herniation may be especially difcult in children, as the more pliable bone may result in trapdoor fractures (Fig. 10). These fractures result when the bone of the inferior orbit
is displaced inferiorly and forms a greenstick fracture. The pliable bones

Fig. 10. Orbital trapdoor fracture. (A) The small mass of soft tissue at the maxillary sinus
roof could be confused with blood, but it actually represents a herniated and incarcerated right
inferior rectus muscle. Note the loss of the inferior rectus muscle shadow (compare with right
eye, arrowhead). (B) The fracture is subtle on bone windows because the displaced bone has
snapped back into place. (C) Postoperative coronal CT scan showing reduction of the fracture
with reappearance of the inferior rectus muscle shadow within the orbit.

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then snap rapidly back into to a near-normal position, but the inferior rectus
muscle can become trapped in the fracture line in the process. This may
occur without any evidence of bone loss in the orbital oor or blood or
soft tissue in the maxillary sinus. CT ndings in trapdoor-type fractures
can be quite subtle, and may be overlooked if they are not actively sought
[41]. One characteristic nding in such fractures is the loss of the inferior rectus muscle in the orbit (see Fig. 10). Coronal reformats are critical in the
evaluation of the orbital oor.
The second indication for treatment is to prevent postoperative globe
malposition and its resulting complications of diplopia or enophthalmos.
Because of the diuse soft tissue edema associated with facial fractures, it
can be dicult to assess in the acute setting whether or not a patients fractures will result in globe malposition after the swelling has resolved.
Although there is no set rule, many surgeons believe that orbital reconstruction is necessary in the following situations: (1) early clinical enophthalmos,
before the soft tissue edema has dissipated, (2) displacement of greater than
50% of the orbital oor (Fig. 11), (3) orbital volume change greater than 1.5
mL (5% of normal orbital volume), and (4) signicant fat or soft tissue displacement [3943].
The third indication for surgery of the orbit is when the force of the
impact is so severe that the lateral orbital wall (orbital plate of the sphenoid
bone) impacts into the orbital apex or middle cranial fossa (Fig. 12). In such
cases, surgery may be indicated for decompression of neural structures [39].
The surgeon should be cautioned, however, that surgical intervention may
worsen a tenuous situation, (ie, secondary to intraoperative compression/

Fig. 11. Large orbital oor fracture. Coronal reformatted CT shows a fracture encompassing
almost the entire orbital oor (arrowheads). Fractures of greater than 50% of the orbital oor
are usually repaired surgically.

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Fig. 12. High-impact orbital fracture. The orbital oor fracture on this axial CT extends from
the inferior orbital rim (arrow) all the way to the apex (arrowhead), where it involves the lateral
wall of the optic canal. Extension to the rim or apex indicates high traumatic force, and is an
important factor in surgical repair.

manipulation of the orbital apex), and preoperative consultation with an

ophthalmologist is recommended.
Clinically-relevant radiology reports: Orbital fractures
1. Note the presence or absence of extraocular muscle herniation. Muscle
entrapment is a surgical emergency, so when herniation is identied on
CT, the surgeon should be notied immediately.
2. Determine whether the orbital fracture is an isolated blowout fracture,
or part of a larger fracture pattern (ZMC, NOE, Le Fort).
3. Identify which orbital walls are fractured: when one wall is fractured,
look carefully at the other walls.
4. Estimate the size of each of the fractures (ie, in cm2 or in percentage of
oor/walls) and the degree of displacement of fat and soft tissues.
Le Fort fractures
More than 100 years ago, Rene Le Fort devised a classication system for
midface fractures. This classication scheme is based on his nding that
blunt trauma tends to cause fractures along three particular lines of weakness inherent in the design of the facial skeleton [38]. Le Fort based his system on his observation of experimental fractures made in cadavers.
Fractures occurring in 21st-century, real-life situations (in particular,
high-velocity motor vehicle accidents) often deviate from this classication
system, and pure Le Fort fractures are rare. Nevertheless, the Le Fort

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classication system is widely known, and it provides a method for concise

communication of fracture patterns between clinicians and radiologists.
Structures involved
There are three types of Le Fort fractures (Fig. 13). Each Le Fort level
describes not an isolated fracture, but rather a pattern of fractures involving
multiple facial bones. The most consistent and uniting feature of the Le Fort
fractures is the presence of bilateral pterygoid fractures. Pterygoid fractures
are found in all three classes of Le Fort fractures, and are the key to establishing the diagnosis [44]. If a CT reveals bilateral pterygoid fractures, a Le
Fort fracture should be suspected. Conversely, if the CT scan does not
reveal pterygoid fractures, the Le Fort fractures can be excluded [44].
The Le Fort I fracture is a horizontal fracture through the maxilla,
cephalic to the maxillary dentition. Bones fractured in a Le Fort I pattern
include the lower nasal septum, the inferior portion of the piriform apertures, the canine fossae, both zygomaticomaxillary buttresses, the posterior
maxillary walls, and the pterygoid plates. The Le Fort II fracture is often
described as being pyramidal in shape [44]. It traverses the nasofrontal junction and extends laterally across the medial orbital wall, orbital oor,
infraorbital rim, and then through the zygomaticomaxillary suture line. It
also proceeds posteriorly through the nasal septum and pterygoid plates.
The Le Fort III fracture is a complete craniofacial separation, resulting in
separation of the facial bones from the cranium along the line of the nasofrontal and zygomaticofrontal suture lines. As in Le Fort II fractures, the
fracture transverses the nasofrontal junction and extends laterally through
the orbit; however, Le Fort III fractures involve not only the medial and
inferior orbital walls but also the lateral orbital wall, zygomaticofrontal
suture line, and zygomatic arch. As with the other Le Fort fractures, the
fracture line also extends posteriorly through the nasal septum and pterygoid plates.
Each Le Fort fracture pattern has at least one unique component fracture
that is easily recognizable and separates it from the other Le Fort fractures
[44]. Rhea and Novelline recently used these unique identifying fractures to
design a simple method for identifying and classifying facial fractures [44].
Only the Le Fort I fracture involves the lateral aspect of the piriform aperature. Only the Le Fort II fracture involves the inferior orbital rim and
zygomaticomaxillary suture line. Finally, only the Le Fort III fracture
involves the zygomatic arch and the lateral orbital wall. When midfacial
fractures are present and a Le Fort fracture pattern is suspected, the authors
recommend rst looking at the pterygoid plates. If there is a bilateral pterygoid fracture, a Le Fort fracture is likely present. The next step is to inspect
the three dening fractures discussed above: the lateral piriform aperatures,
the inferior orbital rim, and the zygomatic arch. The presence or absence of
each of these fractures determines whether a fracture of that type is present

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or absent [44]. For example, the absence of a lateral piriform fracture rules
out a Le Fort I; the presence of a zygomatic arch fracture makes is likely
that a Le Fort III fracture is present.
The nal step is then to look systematically for fractures of the other
bones that are involved in the Le Fort levels. This is important because it
is possible to have a Le Fort fracture on one side and an isolated ZMC
or NOE fracture on the other side. The presence of the key indicator fractures does not denitively diagnose the Le Fort level; instead, it serves to
alert the radiologist to the high likelihood of a particular Le Fort fracture.
The other associated fractures must still be identied. Finally, it is possible
to have more than one Le Fort level on a single side of the facial skeleton
[44]. For this reason, all three key indicator fractures must be examined,
allowing each Le Fort level to be ruled in or ruled out, regardless of whether
there is a coexisting Le Fort fracture of a dierent level [44].
Variables aecting treatment
Le Fort fractures result in both a cosmetic and a functional decit. As
discussed above, the facial skeleton is formed by a combination of the relatively strong bones forming the midfacial buttresses, and the more fragile
bones containing air-lled sinuses that lie deep to the buttresses (see
Fig. 1). Le Fort fractures generally disrupt both. These fractures are caused
by forces strong enough to break the buttresses, which then collapse internally and result in the secondary fracture of the more fragile internal bones.
The result, as with NOE fractures, is retrusion of the central midface. In
addition, Le Fort fractures may result in a loss of the vertical height of
the face as a result of interruption of the vertical buttresses. Finally, the
force required to cause a Le Fort fracture generally results in other facial
bone fractures, and these add to the diculty of the surgical repair.
Fractures of the hard palate or dentoalveolar units are frequently associated with Le Fort fractures (Fig. 14). The presence of such fractures is clinically important, as they further disrupt the patients occlusion, adding
signicantly to the complexity of fracture repair. To achieve normal midface
projection, normal occlusion must be restored before anchoring the upper
midface to the maxilla. Similarly, the presence of a coexisting mandibular
fracture will aect the occlusion. For Le Fort II and III fractures, associated
ZMC, NOE, or frontal sinus fractures must be recognized. The frontal bar
must be reconstructed before the midface can be resuspended to it.
The goals of treatment are thus to restore occlusion, facial height, and
facial projection. Knowledge of the Le Fort levels involved on each side is
crucial when making the operative plan, as the surgical access incision
depends greatly on the level of fracture. Le Fort Level I fractures may be
accessed via a gingivo-buccal sulcus incision, whereas Le Fort II and III fractures may require a coronal and possibly an orbital access incision such as the
transconjunctival or subcillary approach [45]. The nal consideration is the

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Fig. 14. Axial CT scan demonstrating oblique palatal fracture (arrows) in a patient with bilateral Le Fort fractures. The presence of associated palatal fracture adds to the diculty of establishing dental occlusion before fracture reduction.

degree of comminution of the involved bones. The buttresses must be recreated to restore facial height and projection. If the buttresses are severely comminuted, they may be inadequate for this function, and bone grafting may be
necessary.
A nal consideration, as with other high-energy fractures, is the orbital
apex. Many Le Fort fractures extend to the anterior cranial base, and in
doing so the fracture lines traverse the orbital apex. Although not described
by Le Fort, some authors refer to this type of fracture as a Le Fort IV
fracture [29,45]. Le Fort fractures are frequently reduced with disimpaction
forceps and a great deal of manual force. Fracture lines through the orbital
apex and close to the carotid canal must be identied on preoperative CT
scan to alert the surgeon to use a more gentle reduction technique to avoid
disrupting the fractured bones in these critical areas [29].

;
Fig. 13. Le Fort fractures. (A) Schematic of the Le Fort fracture patterns. (From Linnau KF,
Stanley RB Jr, Hallam DK, et al. Imaging of high-energy midfacial trauma: what the surgeon
needs to know. Eur J Radiol 2003;48:1732; with permission.) (B) Axial CT scan demonstrating
fractures of the bilateral pterygoid plates (arrows). Presence of bilateral pterygoid plate fractures is strongly suggestive of the presence of Le Fort fractures. (C) Coronal reformat of
a Le Fort I fracture shows fracture lines extending though the walls of the maxillary antrum
(arrows) and across the nasal septum, without orbital involvement. (D) Coronal reformat of
a LeFort II fracture shows fracture lines through the maxillary antrum (arrow), and through
the inferior and medial walls of the orbital (arrowheads), as well as the nasal bridge. (E) Coronal
reformat of a Le Fort III fracture shows fractures though the zygomatic arch and lateral orbital
walls (arrow), as well as the orbital roofs (arrowhead).

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Clinically relevant radiology reports: Le Fort fractures

1. Indicate which Le Fort levels are involved. Le Fort levels may dier
between the two sides of the face, and fractures may occur through
more than one Le Fort level on the same side of the face.
2. Other facial fracture patterns such as NOE, frontal sinus, and ZMC
fractures frequently occur in association with Le Fort fracture patterns,
and should be noted.
3. Fractures of the hard palate, maxillary dentoalveolar units, and mandible will aect occlusion and thus aect the repair; these injuries should
be specically sought.

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