Brief outlook on fractures of middle third of face

1. Fractures of middle third of face
Kaushik.P
4050

2. Naso-orbital Fractures
 Direct force over the nasion fractures nasal bones and
displaces them posteriorly.
 Perpendicular plate of ethmoid, ethmoidal air cells and
orbital wall are fractured and driven posteriorly.
 Injury may involve cribriform plate, frontal sinus,
frontonasal duct, extraocular muscles, eyeball and lacrimal
apparatus.

3. Clinical features –
•Telecanthus due to lateral displacement of medial orbital wall
•Pug nose, i.e, bridge of nose is depressed and tip is turned up
•Periorbital ecchymosis
•Orbital haematoma
•CSF leakage due to fracture of cribriform plate and dura
•Displacement of eyeball.
Diagnosis – By multiple facial films and also to asses the extent of
injury.

4. Treatment
 Closed reduction- Fracture is reduced with
Asche’s forceps and stabilized by a wire passed
through fractured bony fragments and septum.
Splinting is kept for 10 days or so.
 Open reduction- An H-type incision gives
adequate exposure of fractured area.
Nasal bones are reduced under vision and
bridge height is achieved. Medial orbital walls can
be reduced. Medial canthal ligaments if avulsed
are restored. Intranasal packing is required to
restore the contour.

5. Fractures of zygoma (Tripod fracture)
Zygoma is the second most
commonly fractured bone usually due
to direct trauma. Zygoma is separated at
its three processes. Fracture line passes
through zygomaticofrontal suture,
orbital floor, infraorbital margin,
anterior wall of maxillary sinus and
zygomaticotemporal suture.

6. Clinical features-
•Flattening of malar prominences
•Step deformity of infraorbital margin
•Anaesthesia in the distribution of infra orbital
nerve
•Trismus
•Restricted ocular movements, may cause diplopia
•Periorbital emphysema
Diagnosis- Waters view or exaggerated waters view
shows the fracture and displacement the best.

7. Treatment-
Only displaced fractures require treatment. Open reduction and
internal wire fixation gives the best results. Fracture is exposed at
the frontozygomatic suture and reduced by passing an elevator
behind the zygoma. Wire fixation is done at frontozygomatic suture
and infraorbital margin.
Transantral approach can also be done but its less favourable.

8. Fractures of Zygomatic Arch
Zygomatic arch generally breaks into two fragments which get
depressed. Fracture lines are at each end and one in the centre.
Clinical features-
•Depression in the area of the arch
•Local pain
•Trismus or limitation in the movements of mandible

9. Diagnosis-
Submentovertical view of the skull best shows the fracture.
Treatment-
Vertical incision is made cutting through temporal fascia. An elevator is
passed deep to temporal fascia and carried under the depressed bony
fragments which are then reduced. Fixation is usually not required as the
fragments remain stable.

10. Fractures of Orbital Floor
Zygomatic and Le Fort II maxillary
fractures are almost always
accompanied by fractures of the
orbital floor.
Isolated fractures of the orbital
floor, when large blunt object
strikes the globe are called ‘blow
out fractures’.

11. Clinical features-
•Ecchymosis of lid, conjunctiva and
sclera
•Enophthalmos with inferior
displacement of the eyeball
•Diplopia
•Hypoesthesia of cheek and upper lip if
infraorbital nerve is involved
•Sometimes epistaxis may also be seen
on the injured side.

12. Diagnosis-
•X-ray Waters view will show convex
opacity bulging into the antrum from
above- Tear drop opacity. CT scans
may confirm the diagnosis.
•Entrapment of the inferior rectus and
inferior oblique muscles is diagnosed
by asking patient to look up and down
or by traction test, in which the globe is
grasped and passively rotated to check
for restriction of movements.

13. Treatment-
Indications for surgery are
•Enophthalmos and persistent diplopia.
Orbital fractures can be satisfactorily reduced by a finger passed into the
antrum through transantral approach. A pack can be kept in the antrum to
support the fragments.
Infraorbital approach can be used in combination with transantral approach or
even alone.
Badly comminuted orbital floor fractures can be repaired by a bone graft from
iliac crest, nasal septum or anterior wall of the antrum. Silicon and Teflon
sheets can also be used.