Facial Fractures

Facial fractures are breaks of the nasal bones, orbit, zygoma, maxilla or mandible, common in contact sport, assault and road traffic collisions.

Nasal fractures are the commonest. The priority is recognising the patterns that cannot be missed: airway compromise, orbital compartment syndrome, the paediatric white-eyed trapdoor fracture, septal haematoma and a cerebrospinal fluid (CSF) leak. Screen every sport-related case for concussion.

The face is built around vertical and horizontal buttresses that absorb impact. The orbit has 4 walls; the medial wall (lamina papyracea) and the floor, over the maxillary sinus, are the thinnest.

Named patterns:

• •Nasal bone fracture: commonest, with cosmetic and airway implications
• •Zygomatic complex (tripod) fracture: through the zygomaticofrontal, zygomaticomaxillary and zygomaticotemporal sutures plus the orbital floor
• •Orbital floor blow-out: force through the globe blows the thin floor into the maxillary sinus, risking inferior rectus entrapment
• •Paediatric trapdoor (white-eyed) blow-out: a greenstick floor snaps back over the muscle, a surgical emergency
• •Mandibular fractures: often bilateral because the mandible is a ring; a bilateral parasymphyseal (flail) pattern threatens the airway
• •Le Fort I to III: all involve the pterygoid plates; III is craniofacial dissociation

The mandibular condylar neck acts as a fuse, breaking to stop the condylar head being driven into the middle cranial fossa.