1. Lisa Publicover August 2005
Facial Fractures
Lisa Publicover
August 2005

2. Outline of Lecture Introduction Skeletal Anatomy Fracture Patterns
Nasal
Zygomatic
Maxilla
Blowout
Frontal Sinus and Nasoethmoidal
Mandibular
Approach to a Suspected Facial Fracture

3. Anatomy The face is composed of 14 bones: Mandible (1) Vomer (1)
Maxilla (2)
Zygomata (2)
Nasal (2)
Lacrimals (2)
Palatines (2)
Inferior Nasal Conchae (2)

4. Image from http://face-and-emotion. com/dataface/physiognomy/cranium

5. 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

6. The Volmer A small, narrow bone
Forms the inferior part of the nasal septum

7. 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

8. The Zygomata Paired Form the “cheekbones”
Articulate with the temporal, frontal, and maxillary bones
Their prominent position and shape renders them susceptible to injury

9. The Nasal Bones Paired Join in the midline to form the nasal bridge
They articulate with the frontal, maxillary, and ethmoid bones.

10. The Lacrimal Bones Paired Small & Fragile Located in the
medial wall of each orbit
Contains a small fossa,
which houses the lacrimal
apparatus

11. The Palatine Bones Paired Located posterior to the maxilla
Form the posterior part of the lateral wall of the nasal cavity

12. The Inferior Nasal Conchae
Paired
Located within the nasal cavity
Project medially from the lateral walls of the nasal cavity

13. Fracture Patterns Nasal Zygomatic Maxilla Blowout
Lateral Blow
Other
Zygomatic
Maxilla
LeFort I
LeFort II
LeFort III
Blowout
Frontal Sinus & Nasoethmoid
Mandibular

14. 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.

15. Fracture Patterns Nasal Zygomatic Maxilla Blowout
Lateral Blow
Other
Zygomatic
Maxilla
LeFort I
LeFort II
LeFort III
Blowout
Frontal Sinus & Nasoethmoid
Mandibular

16. 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.

17. Fracture Patterns Nasal Zygomatic Maxilla Blowout
Lateral Blow
Other
Zygomatic
Maxilla
LeFort I
LeFort II
LeFort III
Blowout
Frontal Sinus & Nasoethmoid
Mandibular

18. 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

19. Fracture Patterns Nasal Zygomatic Maxilla Blowout
Lateral Blow
Other
Zygomatic
Maxilla
LeFort I
LeFort II
LeFort III
Blowout
Frontal Sinus & Nasoethmoid
Mandibular

20. 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

21. 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

22. 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.

23. 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

24. Fracture Patterns Nasal Zygomatic Maxilla Blowout
Lateral Blow
Other
Zygomatic
Maxilla
LeFort I
LeFort II
LeFort III
Blowout
Frontal Sinus & Nasoethmoid
Mandibular

25. 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

26. Fracture Patterns Nasal Zygomatic Maxilla Blowout
Lateral Blow
Other
Zygomatic
Maxilla
LeFort I
LeFort II
LeFort III
Blowout
Frontal Sinus & Nasoethmoid
Mandibular

27. 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.

28. Fracture Patterns Nasal Zygomatic Maxilla Blowout
Lateral Blow
Other
Zygomatic
Maxilla
LeFort I
LeFort II
LeFort III
Blowout
Frontal Sinus & Nasoethmoid
Mandibular

29. 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

30. Mandibular Fractures (2)
Signs & Symptoms:
Pain
Malocclusion
Excessive salivation
Dysphagia
Swelling
Crepitation
Discoloration
Deformity

31. Approach to a Suspected Fracture
History
Symptoms
Physical Examination
Imaging

32. History Cause of Fracture Degree of Force Specific Symptoms
Time since injury
Allergies
Medications
Etc.

33. Physical Examination Symmetry/Deformity
Lacerations/Abrasions/Ecchymoses
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

34. 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
Lateral
Caldwell

35. References
Grabb, W. & Smith,J. (1979). Plastic Surgery (3rd Ed.). Little, Brown and Company: Boston, MA
University of Washington School of Medicine: