Fig. 3.12  Increase of intercanthal distance caused by a fracture of the right NOE complex. Enophthalmus caused by a right orbital floor fracture

Type 1: Avulsion of the medial canthal ligament Type 2: Unilateral osseous avulsion of the central

bony region with adherent canthal ligament Type 3: Bilateral osseous avulsion of the central bony

region with adherent canthal ligament (Fig.  3.11)

Canthal ligament injuries with disruption of the central fragment result in an increase in the intercanthal distance, due to the lateral position of the median canthi. The medial canthus is dislocated laterally; the curvature of the palpebral fissure vanishes through contraction of the orbicular muscle and is also laterally dislocated due to a laxity of the eye lids (Mathog 1992; Meleca and Mathog 1995; Mathog et al 1995). In type-3 NOE fractures, there is a comminution of the NOE complex with bilateral displacement of the medial orbital walls (central fragment) with adherent medial canthal ligaments. This results in flattening and widening of the naso-orbital complex and increase of the intercanthal distance (Figs. 3.12–3.17).

3.2.8  Cranio-Frontal Fractures

These fractures are staged according to the extent and dimension of the fracture and subdivided into the following fracture types (Bowerman 1985; Hoffman and Krause 1991; Mathog et al. 1995; Baker et al 2003):

•Isolated frontal sinus fractures

•Fractures of frontal sinus and ethmoid

•Fractures of frontal sinus, orbit, ethmoid, and bridge of the nose

Fractures of the craniofrontal region affect approximately 5% of all facial fractures and 2–12% of the cranial fractures (Ioannidis et al. 1993). In frontal sinus wall fractures there may be isolated or combined fractures of the anterior and posterior walls.

The varying fracture types can be differentiated with regard to their pathogenesis and surgical therapy (Godbersen and Kügelgen 1998):

Classification of frontal sinus fractures (Godbersen and Kügelgen 1998)

Type 1

Frontal sinus – anterior wall fracture

Isolated or in combination with midface fractures

Type 2

Frontal sinus – posterior wall fracture without dura defect

Isolated or in combination with anterior wall fracture and other midface fractures

Type 3

Frontal sinus – posterior wall fracture with dura defect

Isolated or in combination with anterior wall fractures and other midface fractures (Figs. 3.18–3.20)

3.3.  Craniofacial Fractures

3.3.1  Skull Base-Related Classification

In comparison with the past, injuries of the facial skeleton have changed considerably with reference to severity, extent, localization, and accident mechanisms, and tend toward a higher incidence of combined and severe facialand cranial injuries (Manson 1986, 1998; Gruss et al. 1989; Hardt et al. 1990; Krafft et al. 1991; Schilli and Joss 1991; Vuillemin et al. 1998).

Craniofacial fractures are characterized by the inclusion of the frontofacial and frontobasal compartments in the midfacial fracture pattern. In many cases there are complex fractures with extensive comminutions and irregular fracture patterns as a result of maxillary, frontobasal, and frontofacial polyfragmentation (Matras and Kuderna 1980; Manson 1986, 1998; Schneider and Richter 1993; Weerda 1995; Hausamen and Schmelzeisen 1996; Joss et al. 2001) (Fig. 3.21).

Based on the modern industrial society of today and the decisively altered fracture mechanisms, Manson