Background:

In approximately 400 BC, Hippocrates

provided the first description of a variety of facial injuries. Rene Le Fort used cadaver studies in 1900 to provide detailed descriptions of 3 basic types of facial fracture.

Pathophysiology

High impact Supraorbital rim: 200 g Symphysis mandible: 100 g Frontal-glabellar: 100 g Angle of mandible: 70 g Low impact Zygoma: 50 g Nasal bone: 30 g

Nasal fracture:
most common of

all facial fractures NOE fractures extend into the nose through the ethmoid bonesprone to cerebrospinal fluid (CSF) leaks from dural tears.

Nasal fx upon P.E.:

swelling, tenderness, and crepitus

over the nasal bridge. The patient may have had epistaxis that has resolved, but no clear fluid (CSF) should be present. NOE fracture: Suspect NOE if the patient has evidence of a nasal fracture with telecanthus, widening of the nasal bridge with detached medial canthus, and epistaxis or CSF

Zygoma fracture:
(tripod) result from a

direct blow to the cheek. occurs at articulations of the zygoma with the frontal bone maxillae and zygomatic arch and often extends through the orbital floor. Because the infraorbital nerve passes through the orbital floor, hypesthesia

Zygoma fx upon PE:

depressed malar eminence with

tenderness suggest a zygoma or zygomatic arch fracture. Often edema is marked, which can obscure the depression. The patient may complain of pain in the cheek on movement of the jaw. The patient may have trismus or difficulty opening the mouth from impingement of the temporalis muscle as it passes under the zygoma.

LE FORT fractures/midface

Lefort 1
Horizontal maxillary fracture separates the maxillary process (hard palate) from the rest of the maxilla. Fracture extends through the lower third of the septum and involves the maxillary sinus. This is below the level of the infraorbital nerve and thus does not cause hypesthesia.

Lefort 1 upon P.E.

facial edema and mobility of the hard

palate. This is evaluated by grasping the incisors and hard palate and gently pushing in and out.

Lefort 2

Pyramidal fracture starts at the nasal

bone, extends through the lacrimal bone, and courses downward through the zygomaticomaxillary suture. It courses posteriorly through the maxilla and below the zygoma into the upper pterygoid plates. The inner canthus of the nasal bridge is widened. Because the fracture extends through the zygoma, near the exit of the infraorbital nerve, hypesthesia often is present.

Upon P.E. Lefort 2

marked facial edema with

telecanthus, bilateral subconjunctival hemorrhages, and mobility of the maxilla. Epistaxis or CSF rhinorrhea may be noted.

Lefort 3

: Craniofacial dysjunction also starts

at the nasal bridge. It extends posteriorly through the ethmoid bones and laterally through the orbits below the optic foramen, through the pterygomaxillary suture into the sphenopalatine fossa. This fracture separates facial bones from cranium,

Upon P.E. Lefort 3

appearance of facial elongation and

flattening (ie, dishface deformity). Maxilla often is displaced posteriorly, causing an anterior open bite. Grasping the teeth and hard palate and gently moving them results in movement of all facial bones in relation to the cranium. CSF rhinorrhea is almost always present but may be obscured by epistaxis.

Inspect face for asymmetry.* Inspect open wounds for foreign

Hx & Physical Examination

bodies and palpate for bony injury.* examine eyes for injuryabnormality of ocular movements, and visual acuity.* Inspect narestelecanthus and widening of the nasal bridge, and palpate for tenderness and crepitus.* Inspect nasal septum for septal

 Palpate zygoma along its arch as well

as its articulations with the frontal bone, temporal bone, and maxillae.* Check facial stability by grasping teeth and hard palate and gently pushing back and forth, then up and down, feeling for movement or instability of midface.* Inspect teeth for fracture and bleeding at the gum line (a sign of fracture through the alveolar bone), and test for stability.*

step-off.* Inspect for bleeding between teeth at the gum line (a sign of mandibular fracture). Palpate mandible for tenderness, swelling, and step-off along its symphysis, body, angle, and condyle anterior to the ear canal. Evaluate supraorbital, infraorbital*, inferior alveolar, and mental nerve distributions for hypesthesia or anesthesia.

Check teeth for malocclusion and

Imaging Studies:
Nasal bone fractures
Nasal bone fractures can be diagnosed

clinically by history and physical examination. Plain nasal films consisting of a lateral view coning down on the nose and a Waters view can confirm the diagnosis but are of little practical use. If deformity persists after resolution of edema, films may be obtained at followup to help plan the repair. Omission of ED films is cost-effective, since most nasal fractures do not need to be reduced.

NOE Fx:
Coronal CT scan of the facial bones is

the best test to determine the extent of fracture. A 3-D reconstruction may help the consultant should surgery be required.

??traumatic teleacanthus

Zygoma Fx:
Best film for evaluating zygomatic

arch is an underexposed submental view, also known as bucket handle view, because arches appear as bucket handles. Fracture also can be seen on a Waters view, and in some cases on a Towne view, of a facial series.

Tripod:
If tripod fracture is suspected, plain

films should include Waters, Caldwell, and underexposed submental views. Waters view is best to evaluate the inferior orbital rim, maxillary extension of the zygoma, and the maxillary sinus. Caldwell view evaluates the frontal process of the zygoma and the zygomaticofrontal suture. Underexposed submental view evaluates the zygomatic arch.

Tripod
Coronal CT scan of facial bones

often is used to better evaluate these fractures, especially with use of 3-D reconstruction to improve visualization of the fracture for reduction. If tripod fracture is suspected strongly, obtaining CT scan directly without plain films is probably most costeffective

Lefort fx
Coronal CT scan of facial bones has

replaced plain films in evaluation of Le Fort fractures, especially with use of 3D reconstruction. Since Le Fort fractures often are mixed from one side to the other, CT scan is superior to plain films and makes visualization of the fracture for repair much easier. If CT is not available, a facial series with lateral, Waters, and Caldwell views can be used to evaluate the fracture. Almost all Le Fort fractures cause blood to collect in the maxillary sinus.

Medications
Provide adequate analgesia, including

opioids, NSAIDs, or local anesthetics. Prophylactic antibiotics are controversial when a CSF leak is identified or when the fracture involves the sinuses. It is usually left to the discretion of the specialist assuming care of the patient. If the nares has been packed for epistaxis, prophylactic antibiotics should be used to prevent infection, including toxic shook syndrome. If the patient has an open wound, update tetanus immunization.

In patient care:
Patients with NOE fractures generally

require admission to monitor for a CSF leak and observe for signs of meningitis or brain abscess, which are known complications. Patients with zygomatic arch fractures who have significant trismus or inability to open the mouth may require admission for observation because of potential problems with aspiration or airway obstruction from vomiting. Patients with tripod fractures with eye involvement generally require admission to ophthalmology.

In px
Patients with Le Fort fractures may require

admission for further workup prior to open reduction and internal fixation. Patients also may need a short admission if arch wires are used, because of the risk of obstruction or aspiration should they vomit. During the hospital stay, teach patients how to remove the crossband so the mouth can be opened if they need to vomit. Patients with multiple traumas should be admitted to a surgeon with trauma experience to coordinate care of all injuries. The incidence of posttraumatic stress

In/Out Patient Meds

Facial fractures tend to be very

painful. Provide adequate analgesia, including oral opioids and NSAIDs. If nasal packing is used, antibiotics are generally used to prevent toxic shock.

Complications
Continued CSF leaks can occur, although

most stop by 2-3 weeks after the injury. Meningitis and abscesses are serious infections that can occur when a CSF leak is present. Observe patients closely for signs and symptoms. Sepsis Scars and facial deformity Injury to infraorbital nerve in tripod and Le Fort II fractures that extends through the infraorbital foramen where the nerve exits Posttraumatic stress disorder