• Usually seen following sporting accidents, interpersonal violence and RTAs
• May be associated with multisystem trauma
• Assessment should follow ATLS principals

Assessment

• Primary survey
  • Airway compromise from a fracture or haemorrhage should be identified
  • Bilateral anterior mandibular fractures may allow tongue to fall back
  • Orotracheal intubation may be required
  • Haemorrhage should be reduced with mouth props and epistaxis balloons
  • Anterior and posterior nasal packing may be required
• Secondary survey
  • Palpate of orbital rims, zygomatic arches and mandible to identify fractures
  • Examine eyes carefully
  • Reduced eye movement may suggest orbital fracture
  • Subconjunctival haemorrhage may suggest skull fracture
  • Proptosis and ophthalmoplegia may suggest retrobulbar haemorrhage
  • Assess sensation in maxillary branch of trigeminal nerve
  • Intercanthal distance should be 30 - 35 mm
  • Intercanthal distance greater than 35 mm suggests a nasoethmoid fracture
  • Interpupillary distance should be 55 mm
  • Intraoral examination is essential
  • Allows assessment of occlusion and intraoral haematomas

Radiology

• May be difficult to obtain films in the acute setting
• Useful radiographs include:
  • Occipitomental views (15° and 30°) for orbital and zygomatic fractures
  • Postero-anterior views of facial bones
  • Submentovertex view for zygomatic arch fractures
  • Orthopantomogram (OPG) for mandibular fractures
  • Reverse Townes view for condyle neck fractures
  • Occlusal films for dento-alveolar fractures
• CT scanning
  • CT scanning allows complete assessment of fractures
  • 3-D reconstruction is useful
  • Allows production of a stereolithograph and a 1:1 resin model from the digital image

Classification

• Fractures usually classified  as
  • Upper third - frontal bones
  • Middle third - zygoma, nasal bones, and maxilla
  • Lower third - mandible and teeth

Le Fort fractures

• Fractures of mid portion of face have been classified as
• Le Fort 1 - Fracture detaching palate and maxillary alveolus
• Le Fort 2 - Pyramidal fracture through sinus wall laterally and nasal bones medially
• Le Fort 3 - Fracture through frontozygomatic sutures and orbits detaching facial skeleton from base of skull

Principals of treatment

• Primary repair produces the best cosmetic results
• May be delayed for 2 or 3 days if multidisciplinary approach required
• Open reduction and internal fixation is treatment of choice allowing:
  • Anatomical reduction of fractures
  • Stable internal fixation
  • Early jaw mobilisation

Bibliography

Swinson B,  Lloyd  T.  Management of maxillofacial injuries.  Hosp Med 2003;  64:  72-78.