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Fractures Of The Facial Skeleton​

Table: Fractures of the face
 Upper third                        Middle third                     Lower third
 Frontal sinus’s                     Nasal bones and septum       Alveolar process                 
Supraorbital ridge              Naso-orbital area                   Symphysis
 Frontal bone                       Zygoma                              Body
                                          Zygomatic arch                   Angle
                                          Orbital floor                        Ascending ramus
                                          Maxilla                               Condyle
                                         - Le Fort I (transverse)        Temporomandibular joint
                                         - Le Fort II (pyramidal)
                                         - Le Fort III (craniofacial dysjunction)


Extra Edge. Costen’s syndrome is abnormality of temporomandibular joint due to defective bite. It is characterised by otalgia, feeling of blocked ear, tinnitus and sometimes vertigo. Pain also radiates to frontal, parietal and occipital region.


  1. Fracture Of The Nose : (Classified )
    1. Class 1 Fracture
      1. Depressed nasal fracture
      2. Force required 25-75 lb/in2
      3. Fracture line runs parallel to the dorsum & the nasomaxillary suture line
      4. NASAL SEPTUM is NOT involved in this injury (In a severe variant it is involved )
      5. Features: DO NOT cause gross lateral displacement
      6. Rx : Fracture reduction done either immediately or after 5-7 days once oedema settles
    2. Class 2 Fracture
      1. Involve the nasal bone, the frontal process of the maxilla and the SEPTAL STRUCTURES
      2. Ethmoidal labyrinth and the orbit are spared
      3. Here the quadrilateral cartilage gets dislocated from the maxillary crest
      4. Rx : Closed reduction of the nasal bone fracture with open reduction of the septum
    3. Class 3 Fracture
      1. Caused by high velocity trauma
      2. Naso-orbitio-ethmoid fracture
      3. Present with multiple fracture of the roof of ethmoid, orbit & sometimes extend as far back as the sphenoid and parasellar regions [C-S.F. leak, pneumo-cranium]
      4. Rx ; Open reduction & internal fixation
  1. Distal part of the nasal bone is half the thickness of the proximal part. Therefore more    susceptible to injury
  2. Untreated nasal bone fractures lasting for more than 21 days require OPEN REDUCTION
  3. Caudal dislocation is a type of class 2 fracture or at times class 1 fracture
  4. Any C-S.F. leak persisting for more than 2 weeks have to be considered for repair
  1. Septal fracture = Septal #’s are of two types
    1. Chevallet --> When the # line is vertical
    2. Jarajavaj Fracture --> When the fracture line in horizontal.

Fig.: Types of fractures. (A) Normal (B) Frontal blow causing depressed fracture or open – book fracture and (C) Lateral blow causing deviation of nasal bridge or depression of none nasal bone.
  1. Mandible
    1. Most common site of fracture : Subcondylar region
    2. Fracture sites : Subcondylar area > angle > body > symphysis
    3. Sub-condylar fracture is caused by : indirect force delivered force delivered either to the chin or the contralateral mandibular body
  2. Treatment:                                                            
    1. Closed reduction technique                                                                             
      1. Dental wiring / Intermaxillary fixation [# in the tooth bearing area]
      2. External pin fixation: for combined fracture of the mandible & maxilla
    2. Open reduction technique
      Condylar neck fracture : Intermaxillary fixation for 10 days followed by jaw exercises or open reduction
    TYPE 1 (Transverse)
TYPE 2 (Pyramidal)
(Infra orbital nerve damage)

Fig: Fracture Zygoma left
  1. Features
  1. Step - deformity at the infra - orbital margin                                                            
  2. Flattening of the malar prominence
  3. Anasethesia in the distribution of the infra - orbital nerve                    
  4. Trismus
  5. Restricted ocular movement                                                                      
  6. Periorbital emphysema
    C.T. Scan (orbit)
  1. Treatment:
    1. Only displaced fractures are to be treated
    2. Open reduction and internal wire fixation is to be carried out.
  1. Orbital Fracture:
    1. Orbital fracture predominantly involved the floor since it is the thinnest wall (0.5-1 mm)
    2. It is commonly found in association with Le fort type - 2 and zygomatic fractures
Blow out fractures of the orbit
Isolated fracture of the orbital floor following injury with large blunt object
  1. Restriction of extra ocular mobility [esp. upward gaze]          
  2. Infra orbital anaesthesia
  3. Exophthalmos                                                                                  
  4. Ecchymosis
  5. Diplopia
  1. Radiology
    P.N.S X-rays ; 70% if them demonstrate orbital fractures
    C.T. Scan : Tear - drop sign in the antrum roof [Due to herniation of the orbital fat]
  2. Treatment
    1. Surgery performed only when Enophthalmus and Diplopia are present
    2. It is performed 7-10 days later or immediately if visual acuity is affected
    3. Caldwell Lucs surgery may be indicated.

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