Facial Fractures

Front 1

Vertical Buttresses

Back 1

1. Naso-maxillary (NM)
2. Zygomatico-maxillary (ZM)
3. Pterygo-maxillary (PM)
4. Nasal septum

Front 2

Horizontal Beams

Back 2

1. Frontal bar
2. Inferior orbital rims
3. maxillary alveolus and palate
4. zygomatic process
5. Greater wing of the sphenoid
6. Medial and lateral pterygoid plates
7. Mandible

Front 3

3 vaults of nose

Back 3

Upper: nasal bones, ethmoid, superior edge of septum, vomer
Middle: upper lateral cartilage, septum, ascending process of maxilla
Lower: lower lateral cartilages, inferior portion of septum

Front 4

Nasal Fractures Classification (Stranc & Robertson)

Back 4

Plane 1: distal ends of nasal bones and septum only

Plane 2: involves entire distal portion of nasal bones and frontal process of maxilla at the piriform aperture. Septum is comminuted and begins to lose height

Plane 3: Involvement of one or both frontal processes of maxilla at the piriform aperture. Fracture extends to frontal bone (NOE)

Front 5

Normal intercanthal distance

Back 5

33mm (>35mm = abnormal)

Front 6

Medial canthal tendon composition

Back 6

anterior limb:
- superficial head of orbic
- inserts onto frontal process of maxillary bone into anterior lacrimal crest

posterior limb:
- deep head of orbic
- inserts onto posterior lacrimal crest

Front 7

Markowitz NOE Classification

Back 7

Type 1:
- single central segment
- no disruption medial canthal tendon (MCT)

Type 2:
- comminuted central segment
- no disruption MCT

Type 3:
- severe comminuted central segment
- disrupted/ avulsed MCT

Front 8

How is the eyelid traction test (Bowstring sign) useful in NOEs?

Back 8

Grasp lower lid with forceps and pull laterally (opposite to MCT)

inability to pull lid taut = complete disruption of MCT

Front 9

4 fractures in an NOE

Back 9

- frontal process of maxilla
- nasal bones
- medial orbital wall
- inferior orbital wall

Front 10

Surgical approaches to NOE

Back 10

1: coronal
2: lower eyelid
3: gingival buccal sulcus incision
4: local incision (vertical, open sky, laceration)

Front 11

How to repair medial canthal tendon in NOE fracture

Back 11

- Transnasal wiring (30 gauge wire)
- posterior/superior to lacrimal apparatus
- tendon repaired with 2-0 nonabsorbable suture

Front 12

What drains into middle meatus?

Back 12

maxillary sinus, frontal sinus, anterior cells of ethmoid sinus

Front 13

What drains into inferior meatus?

Back 13

Nasolacrimal canal

Front 14

What drains into superior meatus?

Back 14

posterior ethmoidal cells

Front 15

What is the Foramina of Breschet?

Back 15

- site of venous drainage of the frontal sinus mucosa

- potential route of intracranial spread of infection

Front 16

What is the risk if mucosa of frontal sinus is not completely obliterated in cranialization?

Back 16

Mucocele formation

Front 17

What separates frontal sinus from brain?

Back 17

Cribiform plate

Front 18

Indications for surgery in frontal sinus fracture

Back 18

- anterior table displacement with contour change
- nasofrontal duct involvement
- displaced posterior table

Front 19

When do you obliterate frontal sinus?

Back 19

if nasofrontal duct involved

*NOE, medial/superior orbital, orbital floor fractures assumed to have nasofrontal duct involvement

Front 20

When do you perform cranialization?

Back 20

if CSF leak and posterior table is displaced, or if it is non-displaced but leak is persistent > 4-7days

- involves removal of posterior table, obliteration of nasofrontal duct, reduction of anterior wall

Front 21

Muscles that attach to zygoma

Back 21

- masseter
- temporalis
- zygomaticus
- zygomatic head of quadratus labii superioris

Front 22

Fracture sites of Lefort 1

Back 22

AKA Guerin or transverse Fracture

1: Pterygoid plates
2: Pyriform aperture (inferior medial maxillary buttress)
3: alveolar maxilla (inferior lateral maxillary buttress)

Front 23

Fracture sites of Lefort 2

Back 23

AKA Pyramidal fracture

1: pterygoid plates
2: nasofrontal junction
3: medial aspect of inferior orbital rim (transverse maxillary buttress)
4: lateral maxillary buttress

Front 24

Fracture sites of Lefort 3

Back 24

1: pterygoid plates
2: nasofrontal junction
3: entire orbital floor
4: zygomaticofrontal suture (upper transverse maxillary buttress)
5: zygomaticosphenoid suture

Front 25

Hendrickson palate fracture classification

Back 25

Type I Anterior and posterolateral alveolar
Type II Sagittal
Type III Para-sagittal
Type IV Para-alveolar
Type V Complex
Type VI Transverse

Front 26

How common is CSF leak in Lefort 2 and 3?

Back 26

25-50%

Front 27

Most common facial fractures

Back 27

1. Mandible
2. zygoma
3. orbit

Front 28

Percentage of facial fractures with C-spine injury

Back 28

7% (14% of c-spine injuries have facial fractures)

Front 29

Percentage of facial fractures with brain injury

Back 29

68%

Front 30

Percentage of ocular injury

Back 30

25%