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Clinical Presentation
*Telecanthus (not always seen acutely): normal
intercanthal distance is 30-34 mm
Foreshortened and depressed nose
Lack of nasal support on palpation
Subconjunctival hemorrhage
CSF rhinorrhea
Mobility of the medial canthus on bimanual exam
Commonly includes medial canthal ligament–bearing bone
Fracture line through anterior and posterior lacrimal crest
Leads to traumatic telecanthus
Possible damage to nasolacrimal system, leading to
epiphora
Septal Cartilage Fractures: progressive deviation from warping
forces due to perichondrium
Treatment
Principles
Rule out brain injury (frontal lobes, dural tears, and
bone fragments in the brain) and coordinate with
neurosurgery
Early intervention (very difficult to fix if done as a late
reconstruction)
Wide exposure; reduce and stabilize anterior orbital
rim; restore internal orbital architecture with bone graft;
reconstruct glabella, upper nasal region, medial canthi;
and release soft tissue
Exposure
Usually required two to three separate incisions
Nasofrontal area: through laceration, midline nasal, or
coronal incision (best exposure)
Subciliary or transconjunctival: with lateral canthotomy
Upper buccal sulcus: may be required to obtain
adequate reduction
Technique
Subperiosteal dissection to inferior orbital rim and floor.
Asch forceps used intranasally to elevate and reduce
nasal fragments.
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Do not detach canthal ligament from bone fragment if
avulsed.
Preserve medial canthal ligament attachments to the
bone.
Preserve lacrimal sac and nasolacrimal duct
attachment to the bone.
Isolate segments containing canthal ligament, place in
perfect anatomic reduction, and stabilize with rigid
fixation.
Preserve and attach all bone fragments.
Reduction, rigid fixation.
Plates/screws if canthal-bearing segment is large
enough
If canthus is avulsed from bone, reposition using
transnasal wires
*Vector of wire fixation: posterior and superior
Bone graft often needed for medial orbital wall and
floor and for restoration of nasal dorsum height and
contour (cantilever cranial bone graft or rib graft).
External splinting 2 weeks.
FRONTAL BONE/SINUS FRACTURES
Anatomy
Thick anterior table, thin floor (orbital roof), and thinner
posterior table.
Nasofrontal duct is posterior medial in location and runs
through anterior ethmoid bone.
Drains into middle meatus.
*Not present at birth, begins to develop at 2 years old,
and does not reach adult size until 12 years old.
Fracture Classification
Anterior table
Posterior table
Nasofrontal duct involvement
Forces of 800-2200 lb are required for frontal sinus fractures, 23× greater than any other facial bone
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Frequently associated with NOE and midface fractures
Clinical Presentation
Palpable deformity to frontal bone
CSF rhinorrhea
Paresthesia in pattern of supraorbital and supratrochlear
nerves
Inferior globe displacement of orbital roof
Complications
Mucocele; pyomucocele
Osteomyelitis
Infection of orbital contents
CSF rhinorrhea
Halo test/ring sign: fluid is placed on gauze and
concentric rings of blood and CSF form, indicating CSF
leak.
Fluid can be sent for beta transferrin level to confirm
leak.
Indications for Operative Management
Displaced anterior table (leads to contour deformity)
Nasofrontal duct involvement or obstruction (leads to
mucocele)
Depressed posterior table
Treatment Goals
Restoration of contour
Isolation of cranial cavity from upper airway
Construction of safe sinus
Operative Management
Displaced anterior table
ORIF with low-profile miniplates
If comminuted, IO wiring may be needed
Nasofrontal duct obstruction or posterior table
displacement with minimal or no CSF leak. Obliteration
of sinus with bone, fat grafts, or pericranial flaps after
exenteration of sinus mucosa
Posterior table fracture with CSF leak: cranialization
Exenterate sinus mucosa
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Remove posterior table allowing the brain to fill
potential space
Nasofrontal duct obstruction can result in mucopyocele.
To test for patency: instill methylene blue into sinus and
place cotton tip applicator (ie, Q-Tip) endonasally for
confirmation of flow (Table 20-2)
TABLE 20-2 Frontal Sinus Fracture Treatment
Algorithm
MAXILLARY FRACTURES
Anatomy
Four processes: frontal, zygomatic, palatine, and alveolar
Contains maxillary sinus
Muscle attachments include facial expression muscles
anteriorly and pterygoid muscles posteriorly
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Three major buttresses that provide strength (Fig. 20-4)
Figure 20-4 Vertical and transverse
buttresses of the facial skeleton.
(From Mulholland MW, ed. Greenfield’s
Surgery. 5th ed. Lippincott Williams &
Wilkins; 2011.)
Nasomaxillary
Zygomatic
Pterygomaxillary
*Le Fort Classification (Fig. 20-5)
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Figure 20-5 Le Fort fracture patterns.
(From Tasman W, Jaeger EA. Duane’s
Ophthalmology. 2006 ed. Lippincott
Williams & Wilkins; 2005.)
Alternating thick buttresses and thinner segments create
distinct fracture patterns
Usually involve pterygoid plates
Le Fort I: transverse
Fracture at the level of tooth apices above the palate
and alveolus
Separates tooth-bearing maxilla from midface
Extends from pyriform aperture posteriorly through
nasal septum, anterior maxillary wall, lateral nasal wall,
and pterygoid plates
Le Fort II: pyramidal
Fracture crosses nasal bones along
zygomaticomaxillary suture
May involve frontal sinus
Upper jaw and nasal bones mobile as single unit
Le Fort III: craniofacial disjunction
May be minimally displaced with subtle occlusion
problems
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Entire midface is mobile and detached from cranial
base
Fracture though pterygoid plates at a high level
Simultaneous mobility of maxilla and nasofrontal and
zygomaticofrontal regions
Vertical or Sagittal Fractures
Fracture sections maxilla in AP plane
Split palate, less common than Le Fort
Initial Management
ABCs: midfacial fractures are associated with high impact
injury and concomitant C-spine fracture (10%).
IMF reduces fracture and decreases bleeding.
Treatment
Alveolar fractures: apply arch bars, place segment in
occlusion, place IMF wires, 2-0 plates to stabilize fracture
Le Fort fractures: primary bone grafts and rigid fixation
IMF 4-6 weeks
Ensure proper reduction of nasomaxillary and
zygomaxillary buttresses
Surgical steps
MMF to reestablish proper occlusal relations. This will
usually establish the known starting point, mandible to
crania base (may be difficult in the presence of split
palate, alveolar, or mandible fx).
Expose widely. May require multiple incisions—
coronal, upper buccal sulcus, transconjunctival,
depending on the location of fractures.
Reduce each segment anatomically starting from
mandible → maxilla → zygoma → NOE, etc.
Stabilize with mini-plates. Le Fort II must stabilize
nasofrontal jx and infraorbital rims; Le Fort III must
stabilize zygomaticofrontal suture.
Primary bone grafting utilized in the acute setting.
Bridge gaps >0.5 cm of maxillary buttresses, >1.5 cm
of antral wall.
Soft tissue suspension of check to infraorbital rim.
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Immobilization in MMF is not necessary for the healing
of Le Fort fx if rigid fixation is utilized in the fx repair.
For Le Fort fx without mobility (<10%), place in MMF
with elastics. If occlusion is not restored in 3 days, do
ORIF, otherwise keep in MMF for 6 weeks with soft
diet.
If the patient is allowed to return to early fx, soft foods
only as true rigid fixation in the midface is not
completely attained due to the thin bones and
corresponding thin plates and screws.
If the mandible is fractured at the condyle—cannot rely
on mandible to establish proper facial height. ORIF
midface first and star with the zygoma then place the
patient in MMF and treat the mandible as indicated.
If the palate is fractured, it may be helpful to first wire
the posterior aspect of the palate for stability before
MMF or any midfacial plating is undertaken.
Most common complication of Le Fort is reduced facial
height and projection.
Common inadequate fixation sequelae: enophthalmos,
malocclusion, increased facial width, soft tissue descent,
facial diastasis, and fat atrophy
Complications: hemorrhage, airway compromise,
pneumocephalus, open bite, nonunion, and malunion
TEMPORAL BONE TRAUMA
Clinical Signs
Facial palsy
10%-50% of temporal bone fractures
Management:
Observation for incomplete paresis
Surgical exploration for complete paresis that is
not recovering
Bruising over mastoid (Battle sign)
Hemotympanum
CSF leak
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Vestibular dysfunction
PALATE FRACTURES
Indications for Surgery
Anterior-posterior–oriented fractures with large individual
segments and no comminution.
Palatal splints are used for complex fractures to provide the
best vault stabilization.
Surgical Approach
Avoid devascularizing the buccal, gingival, or palatal
mucosa during fracture exposure.
Full open reduction must include reduction and stabilization
of the palatal vault, dental arch (alveolus and pyriform
aperture), and the four anterior vertical buttresses of the
maxilla.
Place the patient in MMF for 2-6 weeks.
Splints only to supplement fixation.
PANFACIAL FRACTURES
Definition: facial fractures that involve the upper, middle, and
lower (mandible) face
Goals
Reestablish proper vertical columns and anterior facial
projection via anatomic reduction and rigid fixation of the
facial skeletons
Reestablish functional occlusion and orbital/oral/nasal
volume
General Principles (Fig. 20-6)
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Figure 20-6 Panfacial fracture treatment
protocol, based on reconstructing load-
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