> [!Key Points] > 1. look for secondary fracture signs: fluid in a sinus, gas outside a sinus > 2. know key facial sutures > 3. look carefully at orbital blowout fractures for herniations > 4. look at extraconal space for haematoma > 5. pterygoid fracture? think Le Fort #radiopaedia see also: [[Head trauma radiology]], [[eye trauma]], [[Lateral canthotomy]] > [!references]- > - [Rosen Facial trauma](x-devonthink-item://43759332-CF2C-4849-9ADD-BA663F014002) > - [Moore Facial Trauma](x-devonthink-item://3673A856-E48F-44F0-83B7-25775BEEF8BF?page=444) > - [Face radiology Schwartz](x-devonthink-item://2A71AF1A-4715-4D5F-9841-03401D8E6C4E?page=525) > - [Face Radiology Saunders](x-devonthink-item://6D4FAD5A-4759-4128-ACFA-299C7E359B17?page=57) > - [Hayes' zygomatic fracture](x-devonthink-item://1FEB7741-5EF2-46F0-91EE-FE5FAA396D75) > - [Dunn - zygomatico-maxillary trauma](x-devonthink-item://D9FFA39C-F860-4499-BC68-45F0410C37CD) ![[Pasted image 20230511004246.png| Source: http://imagingpathways.health.wa.gov.au]] # Anatomy ![[Pasted image 20241101181407.png]] ![[Pasted image 20241102095227.png]] ![[Pasted image 20241108154552.png|Orbital anatomy on CT]] ![[Pasted image 20241101184304.png|screenshot from X-anatomy]] ![[Pasted image 20241108160329.png]] ![[Pasted image 20241108161605.png]] # ?plain films - somewhat debate, depends on availability - generally CT is gold standard - not many surgeons can plan operative management of mandibular fracture without CT # review 4 sutures 1. zygomatic-temporal suture - along zygomatic arch 2. zygomatic-maxillary suture / buttress - from inferior orbital rim and floor through maxillary sinus walls 3. fronto-zygomatic suture - along lateral orbital rim 4. fronto-nasal suture 5. zygomaticosphenoid suture - along lateral orbital wall ![[Pasted image 20241102095325.png]] Also review pterygoid plates (important for Le Fort fractures) # Review for midface injury look for fractures and: - fluid level in maxillary antrum - sinus air in soft tissues or in the orbit 1- zygomatic arch 2- frontal process of zygoma 3- orbital floor/rim 4- lateral wall of maxillary antrum > if any one of the legs is fractured then always check whether the other three legs of the midface stool are intact (Tripod fracture) ![[Pasted image 20241101181759.png]] # Facial support structures ![[Pasted image 20230511010308.png]] ![[Pasted image 20230511010352.png]] # Orbital floor blowout fracture ![[Pasted image 20230511005809.png]] ^ this fracture noteworth because enters canal for infraorbital nerve - may have some parasthesia below the eye - due to [[Cranial nerve palsies|infraorbital nerve]] (branch of V2 maxillary nerve) involvement - a lot of orbital fat herniating inferiorly, bringing the **inferior rectus muscle** down through the floor defect - won't be able to tract properly; will need fixation # Le Fort fractures see: [Atlas of Emergency Radiology - Le Fort fractures](x-devonthink-item://B6184854-F3D2-4BE0-A504-1FC8656F4BD8?page=58) ![[Pasted image 20230511010807.png]] > must have a **pterygoid plate fracture** to have a le fort fracture > can be bilateral or unilateral > if fronto-nasal suture involved, then Le Fort II or III ![[Pasted image 20240922214408.png|green is sphenoid; bottom part is the pterygoid plate of the sphenoid]] ![[Pasted image 20241101183101.png]] ## Le Fort 1 - usually across horizontal bar through the hard palate - horizontal fractures of the maxilla that run above the teeth bearing alveolar process and the nasal floor and hard palate. - It essentially separates the maxillary teeth and hard palate from the rest of the facial skeleton. - "**floating palate**" ![[Pasted image 20240727004321.png]] ## Le Fort 2 - oblique fracture across maxilla across through the bridge of the nose - involves fronto-nasal suture - extend from the upper nasal bridge at the apex, downwards through the medial wall of the orbits then on through the region of the zygomatico-maxillary suture lines. - Essentially separates the nose, maxillary teeth and hard palate from the rest of the facial skeleton - "**floating maxilla**" ![[Pasted image 20240727004340.png]] ## Le Fort 3 - most serious - high fracture through back of orbit, both sutures, nasal, and *fronto-zygomatic sutures* disrupted - extend through the upper nasal bridge, extend bilaterally across the orbits, to extend through the fronto-zygomatic sutures, then down through the zygomatic arches. - separates the entire mid-face skeleton from the base of the skull, (hence "craniofacial disjunction") - "**floating face**" ![[Pasted image 20240727004400.png]] ## management - [[Airway#Trauma airway|airway]] (higher risk with III > II > I) - early intubation - suction blood/secretions - mid-face fracture may need to be manually pulled forward aka manually reduce fracture (protracted anteriorly to provide a clear airway - maintain C spine precautions as able - can stabilise andible with a hard collar - Bleeding - pulling fracture forward can help control bleeding - pharyngeal or nasal packing may be required - may need operative fixation or arterial ligation / embolisation - FFP / MTP as required **things to note if handing over to aeromedical [[Retrieval medicine|retrieval]]** - volume and content of nasal packs - presence and number of oral packs - ETT balloon pressure - vol of ongoing blood loss to plan for suction and/or transfusion - presence or absence of pneumocephalus for flight planning ### Facial packing indications: major maxillofacial trauma pt with threatened or confirmed airway obstruction and/or major haemorrhage contraindications: none in setting of acute facial trauma that satisfies above indications complications: migration of rapid rhino posterior or through base of skull fracture, aspiration/ingestion of bite blocks and/or oropharyngeal packing 1. secure [[Airway#Trauma airway|airway]] 1. suction airway contamination ducanto 2. consider [[Tracheostomy|cricothyrotomy]] if needed 2. insert orogastric tube 3. insert bilat bite blocks (7.5cm crepe bandages cut in half) to maintain reduction and prevent migration of the midface 1. ensure anatomical alignment of maxilla -- gentle repositiioning of mandible with forward traction may be required 2. insert appropriately sized crepe bandage bite block on either side of the mouth btwn the rear molars to brace the hard palate against the lower jaw 4. apply a Cervical collar to brace the mandible 5. apply direct pressure haemorrhage control by packing the oropharynx with combine dressing 6. consider using Rapid Rhino nasal packs to splint the midface and reduce fractures ![[Pasted image 20240925061916.png]] # Tripod Fracture see: [Atlas of emergency radiology - zygomaticomaxillary complex fractures](x-devonthink-item://B6184854-F3D2-4BE0-A504-1FC8656F4BD8?page=54), [RMH 2023 OSCE - Tripod fracture](x-devonthink-item://B66FC3E6-1950-414A-A386-FEAC079B3C1E) aka: *Zygomaticomaxillary comple fracture* (ZMC), Zygomaticofacial fracture, and Trimalar fracture In ZMC fracture, the cheekbone (zygoma) is detached from its four points of attachment to the rest of the facial skeleton. usually due to direct blow to malar area (cheek bone). 1. fracture through *zygomatic arch* 2. widening (diastasis) of *zygomatico-frontal suture* 3. fracture through the *inferior orbital rim* and lateral orbital rim 4. fracture through the *lateral wall of maxillary antrum* **complications:** - extraocular muscle entrapment leading to [[Diplopia]], especially on upward gaze - infraorbital nerve injury causing numbness/parasthesia to lower lid, cheek, nose, and upper lip - malunion or non-union of fracture resulting in facial asymmetry - infection (eg CVST, cerebral abscess) - orbital compartment syndrome leading to vision loss ![[Pasted image 20241101182250.png]] ![[Pasted image 20241101182509.png| Zygomatico-maxillary complex fracture aka tripod fracture. 1 - zygomatic arch fracture, 2 lateral orbital rim fracture, 3 inferior orbital rim fracture, 4 lateral wall of maxillary sinus fracture.]] ![[Pasted image 20241101182721.png]] | | Tripod fracture | zygomatic arch fracture | | -------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- | ------------------------------------------------------------------------------------------------------------- | | features | \# through inferior orbital rim, lateral orbital wall, and zygomatic arch | isolated \# of zygomatic arch | | symptoms | - lower eyelid/cheek pain, swelling, ecchymosis<br>- possible diplopia w/ upward gaze due to extraocular muscle contusion or entrapment and orbital haematoma<br>- paresthesia of lower lid, cheek, nose, and upper lip if infraorbital nerve injured<br>- may have trismus and epistaxis | - unlikely to have diplopia or paraesthesia<br>- trismus may be present if involvement of teh masseter muscle | ## CT example ![[Pasted image 20241101182805.png|axial CT at level of zygomatic arch shows fractures through anterior portion of zygomatic arch (arrowhead) and the anterior and lateral walls of maxillary sinus (arrows)]] ![[Pasted image 20241101182847.png|Coronal CT shows fractures of the orbital floor and lateral wall of maxillary sinus (arrowheads). no fracture evident of lateral orbital rim in this image (arrow). orbital emphysema is present (astrisk)]] *another example:* ![[Pasted image 20241101183148.png]] - fracture of zygomatico-temporal arch - fracture of the inferior orbital margin - fracture of superiolateral orbital margin - haematoma in maxillary sinus # Complications ## Orbital ![[Pasted image 20230511011550.png]] ^ large haematoma ![[Pasted image 20230511011559.png]] which is pushing eye forward massive proptosis stretching the optic nerve **vision threating injury** urgent need to discuss with opthal and craniofacial surgery lateral canthotomy ## Vascular ## brain CSF leak # Related Questions ## head trauma - [x] 5Q: [Head injury](x-devonthink-item://2CB6E202-E7C1-46E8-B49F-435AB6C937F0?page=1) -- [Answer](x-devonthink-item://78503782-404C-41A2-A3AE-B1A26F578DF5?page=1) -- [prop](x-devonthink-item://51B63B5B-D684-4BF3-8B62-95FCA5EF7503?page=4) - [x] 6Q: [One Punch Man](x-devonthink-item://CDB16617-3785-40E5-B8BE-5668D2D7A3E7?page=12) -- [Answer](x-devonthink-item://A6CA01E8-9551-45E7-8617-441BE3DBB5D7?page=10) -- [prop](x-devonthink-item://B892F073-9AD2-46E4-98D6-B0574CAA73A3?page=9) ## [[Lateral canthotomy]] - [x] 8Q: [Head Injury](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=14) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=14) -- [prop](x-devonthink-item://68EA6F60-334D-4A94-8327-78286C5F1AED?page=4) - [x] 9Q: [Eye trauma](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=13) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=18) -- [prop](x-devonthink-item://D0A460D5-938B-4002-A684-EFD9189B08C1?page=13) #finishedQs