Facial Fractures 2

8/3/2019 Facial Fractures 2

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FACIAL FRACTURES



Background:

In approximately 400 BC, Hippocrates

provided the first description of a variety of facial injuries.

Rene Le Fort used cadaver studies in 1900 toprovide detailed descriptions of 3 basic typesof facial fracture.



Pathophysiology

High impact

Supraorbital rim: 200 gSymphysis mandible: 100 gFrontal-glabellar: 100 gAngle of mandible: 70 g

Low impact

Zygoma: 50 gNasal bone: 30 g



Nasal fracture:

most common of

all facial fractures

NOE fractures extend into

the nose through the

ethmoid bonesproneto cerebrospinal fluid (CSF)

leaks from dural tears.



Nasal fx upon P.E.:

swelling, tenderness, and crepitus over thenasal bridge. The patient may have hadepistaxis that has resolved, but no clear fluid(CSF) should be present.

NOE fracture: Suspect NOE if the patient hasevidence of a nasal fracture with telecanthus,

widening of the nasal bridge with detachedmedial canthus, and epistaxis or CSFrhinorrhea.



Zygoma fracture:

(tripod) result from a directblow to the cheek.

occurs at articulations of thezygoma with the frontal bonemaxillae and zygomatic archand often extends through the

orbital floor. Because the infraorbital nerve

passes through the orbital floor,hypesthesia often occurs in its

sensory distribution.



Zygoma fx upon PE:

depressed malar eminence with tendernesssuggest a zygoma or zygomatic arch fracture.Often edema is marked, which can obscurethe 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 thetemporalis muscle as it passes under thezygoma.



LE FORT fractures/midface



Lefort 1

Horizontal maxillary fractureseparates the maxillaryprocess (hard palate) fromthe rest of the maxilla.

Fracture extends throughthe lower third of theseptum and involves themaxillary sinus. This is below

the level of the infraorbitalnerve and thus does notcause hypesthesia.



Lefort 1 upon P.E.

facial edema and mobility of the hard palate.This is evaluated by grasping the incisors andhard palate and gently pushing in and out.



Lefort 2

Pyramidal fracture starts at the nasal bone,extends through the lacrimal bone, and coursesdownward through the zygomaticomaxillarysuture. It courses posteriorly through the maxillaand below the zygoma into the upper pterygoid

plates. The inner canthus of the nasal bridge iswidened. Because the fracture extends throughthe zygoma, near the exit of the infraorbitalnerve, hypesthesia often is present. Bilateralsubcutaneous hematomas often are present.



Upon P.E. –Lefort 2

marked facial edema with telecanthus,bilateral subconjunctival hemorrhages, andmobility of the maxilla.

Epistaxis or CSF rhinorrhea may be noted.



Lefort 3

: Craniofacial dysjunction also starts at thenasal bridge. It extends posteriorly throughthe ethmoid bones and laterally through theorbits below the optic foramen, through thepterygomaxillary suture into thesphenopalatine fossa. This fracture separatesfacial bones from cranium, causing the face

to appear long and flat (ie, dish face)



Upon P.E. –Lefort 3

appearance of facial elongation and flattening (ie, dishface deformity). Maxilla often isdisplaced posteriorly, causing an anterior openbite. Grasping the teeth and hard palate andgently moving them results in movement of all

facial bones in relation to the cranium. CSFrhinorrhea is almost always present but maybe obscured by epistaxis.



Hx & Physical Examination

Inspect face for asymmetry.*

Inspect open wounds for foreign bodies andpalpate for bony injury.*

examine eyes for injuryabnormality of ocular movements, and visual acuity.*

Inspect narestelecanthus and widening of

the nasal bridge, and palpate for tendernessand crepitus.*

Inspect nasal septum for septal hematoma &

clear rhinorrhea, which may suggest a CSF*



Palpate zygoma along its arch as well as its

articulations with the frontal bone, temporalbone, and maxillae.*

Check facial stability by grasping teeth andhard palate and gently pushing back and forth,then up and down, feeling for movement orinstability of midface.*

Inspect teeth for fracture and bleeding at thegum line (a sign of fracture through thealveolar bone), and test for stability.*



Check teeth for malocclusion and step-off.*Inspect for bleeding between teeth at the gumline (a sign of mandibular fracture).

Palpate mandible for tenderness, swelling, andstep-off along its symphysis, body, angle, andcondyle anterior to the ear canal.

Evaluate supraorbital, infraorbital*, inferioralveolar, and mental nerve distributions for

hypesthesia or anesthesia.



Imaging Studies:

Nasal bone fractures

Nasal bone fractures can be diagnosed clinically

by history and physical examination. Plain nasalfilms consisting of a lateral view coning down onthe nose and a Waters view can confirm thediagnosis but are of little practical use.

If deformity persists after resolution of edema,

films may be obtained at follow-up to help planthe repair. Omission of ED films is cost-effective,since most nasal fractures do not need to bereduced.



NOE Fx:

Coronal CT scan of the facial bones is the besttest to determine the extent of fracture. A 3-Dreconstruction may help the consultant shouldsurgery be required.

??traumatic teleacanthus



Zygoma Fx:

Best film for evaluating zygomatic arch is anunderexposed submental view, also known asbucket 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 shouldinclude Waters, Caldwell, and underexposedsubmental views.

Waters view is best to evaluate the inferiororbital 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 thezygomatic arch.

.



Tripod

Coronal CT scan of facial bones often isused to better evaluate these fractures,

especially with use of 3-D reconstructionto improve visualization of the fracture forreduction. If tripod fracture is suspectedstrongly, obtaining CT scan directly

without plain films is probably most cost-effective



Lefort fx

Coronal CT scan of facial bones has replacedplain films in evaluation of Le Fort fractures,especially with use of 3-D reconstruction. Since

Le Fort fractures often are mixed from one sideto the other, CT scan is superior to plain filmsand makes visualization of the fracture for repairmuch easier. If CT is not available, a facial series

with lateral, Waters, and Caldwell views can beused to evaluate the fracture. Almost all Le Fortfractures cause blood to collect in the maxillarysinus.



Medications

Provide adequate analgesia, including opioids,NSAIDs, or local anesthetics. Prophylacticantibiotics are controversial when a CSF leak is

identified or when the fracture involves thesinuses. It is usually left to the discretion of thespecialist assuming care of the patient. If thenares has been packed for epistaxis, prophylactic

antibiotics should be used to prevent infection,including toxic shook syndrome. If the patienthas an open wound, update tetanusimmunization.



In patient care: Patients with NOE fractures generally require

admission to monitor for a CSF leak and observefor signs of meningitis or brain abscess, which areknown complications.

Patients with zygomatic arch fractures who havesignificant trismus or inability to open the mouthmay require admission for observation because of potential problems with aspiration or airwayobstruction from vomiting.

Patients with tripod fractures with eyeinvolvement generally require admission toophthalmology.



In px…

Patients with Le Fort fractures may requireadmission for further workup prior to open reductionand internal fixation. Patients also may need a shortadmission if arch wires are used, because of the risk

of obstruction or aspiration should they vomit.During the hospital stay, teach patients how toremove 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 careof all injuries.

The incidence of posttraumatic stress disorder is highin patients with facial injuries, and consultation witha psychiatrist should be considered.



In/Out Patient Meds

Facial fractures tend to be very painful.Provide adequate analgesia, including oralopioids and NSAIDs. If nasal packing is used,antibiotics are generally used to prevent toxicshock.



Complications

Continued CSF leaks can occur, although most stopby 2-3 weeks after the injury.

Meningitis and abscesses are serious infections thatcan occur when a CSF leak is present. Observepatients closely for signs and symptoms.

Sepsis

Scars and facial deformity

Injury to infraorbital nerve in tripod and Le Fort IIfractures that extends through the infraorbitalforamen where the nerve exits

Posttraumatic stress disorder

Facial Fractures 2

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