Otolaryngol Clin N Am 41 (2008) 5176

Facial Fractures: Beyond Le Fort

Rebecca E. Fraioli, MDa, Barton F. Branstetter IV, MDa,b, Frederic W.-B. Deleyiannis, MD, MPhil, MPHa,c,*
a Department of Otolaryngology, University of Pittsburgh Medical Center, Eye and Ear Institute, 203 Lothrop Street, Suite 500, Pittsburgh, PA 15213, USA b Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop Street, Pittsburgh, PA 15213, USA c Division of Plastic Surgery, Departments of Surgery and Otolaryngology, University of Pittsburgh Medical Center, 6B Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA

The management of facial fractures begins with the establishment of an accurate fracture diagnosis. All too often, radiology reports contain a laundry list of fractures without clinical context, without an understanding of fracture patterns, or without categorization by fracture severity, fracture criticality, or the need for surgical repair. For example, a radiology report that focuses on nasal septal fractures, but ignores a medial canthal avulsion, can be annoying or even misleading to the surgeon. Fracture complexes are reproducible, and the terminology of fracture complexes allows for ecient communication between physicians of intricate fracture patterns in the midface. This type of communication requires that the radiologist understand common mechanisms of injury and the fracture complexes that result. The best-known categorization scheme for fracture fractures is that of Rene Le Fort. However, Le Forts work was based on low-speed impact, and does not completely reect the breadth of trauma that is encountered in modern medicine. The purpose of this issue is to provide a broader classication scheme for midface fracture complexes, which incorporates, and yet goes beyond, Le Forts classication. The goal is to encourage more clinically relevant radiology reports, so that surgeons will know what to expect, and radiologists will know what to provide, in the CT evaluation of facial
* Corresponding author. Division of Plastic Surgery, Departments of Surgery and Otolaryngology, University of Pittsburgh Medical Center, 6B Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261. E-mail address: deleyiannisfw@msx.upmc.edu (F.W.-B. Deleyiannis). 0030-6665/08/$ - see front matter 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.10.003

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fractures. Variables that aect surgical management will be emphasized. At the end of each section, there is a short list of pearls for creating clinically relevant radiology reports. This issue is focused on midface fractures; mandibular and skull base fractures are intentionally excluded to retain this focus.

Frontal sinus fractures Fractures of the frontal sinuses comprise about 5% to 15% of maxillofacial fractures [13]. These fractures are generally classied by involvement of the anterior wall (anterior table) or posterior wall (posterior table). In addition, fractures of either wall may be comminuted or noncomminuted, and displaced or nondisplaced. Finally, involvement of either the nasofrontal duct or the anterior cranial fossa dura has important implications for the clinical management of these fractures. The importance of the radiologic diagnosis of frontal sinus fractures is underscored by the fact that before the advent of routine CT scanning for head trauma, 50% of frontal sinus fractures were not identied until after the patient had left the emergency room [4]. The frontal bone is the strongest of the facial bones, and a large amount of force (800 to 2200 lb) is required to fracture the frontal sinuses [5]. The presence of frontal sinus fractures may therefore be considered an indicator of a high-force injury, and should alert the physician to search for other injuries. Additional craniofacial injuries are present in 56% to 87% of patients with frontal sinus fractures [4,611]. An associated cerebrospinal uid (CSF) leak is present in 13% to 33% of patients with frontal sinus fractures [4,6,8,10,12]. Mortality secondary to other associated injuries has been reported at rates of approximately 9% of patients with frontal sinus fractures [6]. Structures involved Each wall of the frontal sinus serves a dual function. The anterior wall of the frontal sinus, formed by the frontal bone, is responsible for the aesthetic contours of the forehead and the superior orbital rims. In addition, this structure serves as the frontal bar, one of the key horizontal buttresses of the facial skeleton (Fig. 1). The frontal bar helps to maintain the horizontal dimension of the face and to provide a stable foundation for the vertically oriented facial buttresses (see Fig. 1) that support the forces of mastication. Fractures of the anterior table may be clinically important either by disrupting the aesthetic contour of the forehead or by destabilizing the frontal bar from which the other facial bones are suspended [13]. The posterior wall of the frontal sinus forms the anterior wall of the anterior cranial fossa, and serves to separate the sinus contents from the cranial vault. Posterior table fractures are therefore skull fractures, and must be recognized and managed as such. The oor of the frontal sinus forms the medial orbital roof; it also

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Fig. 1. The buttress system of the midface. The buttress system of the midface is formed by the strong frontal, maxillary, zygomatic, and sphenoid bones and their attachments to one another. The central midface consists of several fragile bones that easily crumple when subjected to strong forces. These more fragile bones are surrounded by the thicker bones of the buttress system, which provide structure and absorb the forces applied to the face. Most of the forces absorbed by the face are masticatory, therefore the vertical buttresses are the most well developed. These include the medial nasomaxillary buttress and the lateral zygomaticomaxillary buttress. Three horizontal buttresses interconnect and provide support for the vertical buttresses: the frontal bone and supraorbital rims (frontal bar), the nasal bones and inferior orbital rims, and the maxillary alveolus. (From Linnau KF, Stanley RB Jr, Hallam DK, et al. Imaging of high-energy midfacial trauma: what the surgeon needs to know. Eur J Radiol 2003;48:1732; with permission.)

houses the ostium to the nasofrontal duct in its posteromedial aspect [9]. The nasofrontal duct forms the drainage pathway of the frontal sinus into the nose, so obstruction of this pathway can lead to mucocele, mucopyocele, osteomyelitis, and epidural or subdural abscess [12]. Variables aecting treatment There are three main variables to consider when assessing the need for surgical intervention for frontal sinus fractures. These are involvement of the anterior table, disruption of the nasofrontal duct, and involvement of the posterior table. When assessing the involvement of the anterior or posterior tables, the degree of fracture displacement and comminution are also important. An additional factor involved when assessing the posterior table is the likelihood of dural penetration or nasofrontal duct disruption.

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Anterior table fractures Nondisplaced anterior table fractures require no surgical intervention. Displaced anterior table fractures may cause cosmetic deformity because of facial stepos, asymmetry, or attening of the normally convex glabella. Repair of these defects is ideally performed within 10 days of the injury, a time during which soft tissue edema resulting from the trauma may mask the cosmetic deformity. Consequently, radiologic estimates of the degree of displacement of the anterior table and the resultant cosmetic deformity are critical in making the determination of whether to proceed with surgery. Posterior table fractures The management of posterior table fractures remains somewhat controversial. Nondisplaced posterior table fractures are frequently treated conservatively with close follow-up [2,11]. Follow-up should include early and repeated CT scans of the sinuses [3,11]. In contrast, comminuted or displaced posterior table fractures are generally felt to increase the risk of complications and thus merit exploration [3,14]. The presence of pneumocephalus, although not specic, may indicate dural violation, and also may be an indication for surgical exploration of the fracture [14]. Posterior table fractures may be managed with sinus obliteration if the oor of the sinus is not comminuted and there is not a large amount of bone missing (Fig. 2). Severely comminuted or displaced posterior wall fractures frequently require cranialization (Fig. 3) [6,14,15]. Involvement of the nasofrontal duct If the nasofrontal duct is disrupted, operative intervention is necessary. A few recent reports suggest that conservative management with an endoscopic Lothrop procedure when necessary to reestablish the frontal sinus drainage pathway may be an option; however, the most trusted method of management is to obliterate the sinus and nasofrontal duct ostium [11,1619]. Disruption of the nasofrontal duct may be dicult to assess on CT, and intraoperative exploration is often necessary to make the nal determination of future nonfunction of the duct. However, the CT report should indicate the likelihood of duct disruption based on the location and degree of displacement of the fracture. Nasofrontal duct disruption is most likely in cases where there is a displaced anterior table fracture medial to the supraorbital notch and involving either the oor of the frontal sinus, the naso-orbital-ethmoidal (NOE) complex (see Naso-orbital-ethmoidal (NOE) fractures), or both [16]. Clinically relevant radiology reports: Frontal sinuses 1. Indicate whether the fracture involves the anterior wall, posterior wall, or both, as well as the degree of displacement and comminution of the fracture.

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Fig. 2. Frontal sinus obliteration. (A) Axial CT scan demonstrates fractures of both anterior (arrowheads) and posterior (arrow) tables of the frontal sinuses. At exploration, the dura was found to be intact and there was no evidence of CSF leak, therefore cranialization was not performed. However, the presence of an associated severe NOE fracture suggested disruption of the nasofrontal ducts bilaterally, and therefore the sinuses were obliterated bilaterally with concominant plugging of the nasofrontal ducts with calvarial bone grafts (CBGs) and free pericranium. (B) Postoperative axial CT scan showing reduction of the posterior table with xation of the anterior table fractures. (C) Coronal CT scan demonstrating the CBGs used to plug the nasofrontal ducts (wide arrows). Additional CBGs were required in this patient to reconstruct the oor, medial wall, and roof of the left orbit (thin black arrows).

2. For posterior wall fractures, indicate the presence or absence of pneumocephalus with an estimation of the likelihood of dural violation and the degree of bone loss in the posterior wall and oor of the sinus. 3. Indicate the likelihood of nasofrontal duct obstruction based on the fracture location. 4. Comment on any associated brain injury. This is especially important for posterior table fractures. Zygomatico-maxillary complex (ZMC) fractures The malar eminence of the zygoma is the most anterior projection of the lateral face. This prominent position makes the zygoma susceptible to trauma;

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Fig. 3. Frontal sinus cranialization. This patient was involved in a high-velocity motor vehicle collision that resulted in combined anterior and posterior sinus fractures with displacement of the posterior table, dura injury, and frontal contusion. Frontal sinus cranialization was performed using an anteriorly based pericranial ap and CBGs to plug the nasofrontal ducts. The anterior table fractures were managed with open reduction and xation. (A) Preoperative axial CT scan demonstrating anterior and posterior table fractures and associated pneumocephalus (arrow). (B) Postoperative axial CT scan demonstrating cranialization (note the absence of the posterior table). (C) Postoperative sagital CT scan demonstrating cranialization. The arrow indicates the window made in the frontal bone to allow intracranial passage of the pericranial ap. The pericranial ap was draped over the anterior skull base to reinforce the dura.

one study demonstrated zygomatic complex fractures to be the most common type of facial fracture in patients admitted to the hospital following blunt facial trauma [20]. The central portion of the zygomatic bone is sturdy, and contributes to the vertical buttress system of the midface (see Fig. 1); however, the projections of the zygoma by which it articulates with the surrounding facial bones, and the articulating bones themselves, are weaker. This often results in fracture of the zygoma at its suture lines, classically labeled as a tripod fracture in reference to the three anterior suture lines that are fractured: the zygomaticfrontal (ZF), zygomaticotemporal (ZT), and zygomaticomaxillary (ZM) sutures (Fig. 4). However, the zygoma has a fourth articulation site with the sphenoid bone, which is also fractured, and radiographically, ve distinct fractures are demonstrated (lateral orbital wall, orbital oor, anterior

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Fig. 4. Traditional ZMC fracture. (A) Three-dimensional (3D) surface rendering demonstrates disruption of the three suture lines surrounding the malar eminence: the zygomaticofrontal suture (white arrow), the zygomaticomaxiallry suture (black arrow), and the zygomaticotemporal suture (arrowhead). These three sutural disruptions lend the ZMC fracture its nickname, tripod fracture. Note the associated NOE fracture (*). (B) Coronal CT scan showing fractures of the lateral orbital wall (straight arrow), orbital oor (curved arrow), and zygomaticomaxiallary suture (arrowhead). (C) Axial CT demonstrating medial displacement of a bone fragment (arrow) from the lateral orbital wall toward the globe. (D) Postoperative CT scan following removal of the bone fragment and reconstruction of the lateral orbital wall with a relatively radiolucent Lactosorb bioabsorbable plate (arrows). The NOE fracture (arrowhead) has been incompletely reduced.

maxillary wall, lateral maxillary wall, and zygomatic arch). Thus, the name tripod fracture is technically inaccurate. A more compelling reason to avoid the term tripod fracture is because it fails to recognize that this fracture complex is intermediate on a spectrum of injuries that range from an isolated, nondisplaced fracture limited to the zygomatic arch to severe displacement and comminution of the zygoma and surrounding bones. This spectrum of fractures all have similar mechanisms of injury, but dier in the amount of

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force applied and therefore in the degree of bone loss and displacement [20]. For this reason, it is preferable to classify this entire spectrum of fractures together as zygomaticomaxillary complex (ZMC) fractures. Structures involved The zygoma is an approximately quadrilateral-shaped bone. The body of the zygoma forms the malar prominence, which is an important aesthetic feature of the face. A prominent malar eminence has been described as a sign of youth and beauty [21]. Through its attachments to the surrounding facial bones, the zygoma also helps to determine midfacial height and width [22]. From the laterally oriented malar prominence, the zygoma sends four projections that articulate with the surrounding facial bones. Superiorly, the zygoma articulates with the frontal bone at the narrow frontozygomatic suture; medially, it has a wider articulation with the maxilla, involving both the anterior and lateral walls of the antrum. The curved bony strut of the zygoma lying between these superior and medial projections forms the lateral orbital wall and the lateral aspect of the infraorbital rim and orbital oor. Posteriorly, the zygoma articulates with the sphenoid bone, and laterally it extends as the zygomatic arch to attach to the temporal bone at the zygomaticotemporal suture. The presence of the thick bone of the zygoma at the lateral corner of the midface allows it to act as a cornerstone to provide support to the other facial bones [23]. The maxilla directly contacts the frontal bone at the frontomaxillary suture line and the sphenoid bone posteriorly above the maxillary tuberosity and anterior to the sphenopalatine foramen. The zygoma then overlies and reinforces this area through its attachments to the underlying frontal, maxillary, sphenoid, and temporal bones. Variables aecting treatment The goal of reconstruction in ZMC fractures is to restore the height, width, and projection of the malar eminence. The degree of fracture displacement and comminution determines the extent of the surgical exposure needed for repair. Nondisplaced and minimally displaced fractures frequently do not require surgical intervention [20]. Displaced and comminuted fractures generally require open reduction and xation. The rst and most critical step in management of ZMC fractures is achieving adequate reduction [24]. When fractures are not signicantly comminuted, as is the case in a classic tripod fracture, the entire zygoma may be reduced as a single unit. In such cases, ZMC fractures may be managed through the use of limited incisions, in particular an upper gingivobuccal (UGB) incision and a lateral upper blepheroplasty (LUB) incision. Reduction can, in these cases, be accurately assessed by conrming reduction at the ZM suture (through the UGB incision), the ZF suture (through the LUB incision), and the ZS suture (through the LUB incision).

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Accurate depiction of ZMC fracture displacement can be accomplished with CT (Fig. 5). The malar eminence is often displaced posteriorly, but the degree of displacement may be masked clinically by soft tissue swelling (see Fig. 5A). The malar eminence may be rotated internally or externally (see Fig. 5B, C). Occasionally, the zygomatic arch fracture that accompanies ZMC fractures will not be evident radiographically as a discrete linear hypodensity. Abnormal curvature of the zygomatic arch should be considered equivalent to a discrete fracture in this setting (see Fig. 5D). Accurate reduction is more dicult to assess in comminuted fractures. When the zygoma itself is comminuted, it cannot be reduced as a single unit, and accurate reduction at one suture line does not imply adequate

Fig. 5. ZMC variants. (A) Axial CT shows posterior displacement of the ZMC (double arrow). This displacement would be masked clinically by soft tissue swelling (note symmetry of facial soft tissues). (B) Internal rotation (arrow) of a ZMC fracture. Note the increased interzygomatic distance. (C) External rotation (arrow) of a ZMC fracture. Note the decreased interzygomatic distance. (D) Zygomatic arch angulation. Although no discrete fracture line is seen through the arch, it is abnormally angulated (arrow), which is sucient for the diagnosis of ZMC fracture.

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reduction at the others. In such cases, additional incisions may be necessary for fracture reduction and xation. Eyelid incisions (ie, transconjunctival incision with a lateral canthotomy or subciliary incision) provide exposure to the orbital rim. A coronal access incision may be necessary for wider exposure of the zygomatico-sphenoid suture line, lateral orbit, and zygomatic arch. In addition, the high-energy trauma required to create comminuted zygoma fractures frequently also results in comminuted fractures of the surrounding bones. Le Fort, NOE, and panfacial fractures frequently coexist with ZMC fractures [20]. Identication of these coexisting fractures is critical for determining accurate reduction of the ZMC. Failure to recognize coexisting fractures may mislead the surgeon into aligning the ZMC with another segment of the buttress system that is itself displaced; this in turn may result in postoperative cosmetic deformity [24]. Another major variable aecting the surgical management of ZMC fractures is the status of the orbital oor. The zygoma contributes to both the lateral and the inferior orbital walls. Displacement of these walls frequently occurs in ZMC fractures, and may result in an increased volume of the bony orbit. This increase in orbital volume is the most common cause of posttraumatic enophthalmos [25]. Restoration of the pretrauma orbital volume is therefore a primary goal of ZMC fracture management. Before the advent of routine CT scanning for these injuries, the decision of whether or not to explore the orbit was made on a clinical basis. CT scan has been shown to be a reliable method of making the decision of which orbits require exploration [24,26,27]. The ability to make this determination based on the CT scan allows those patients without signicant orbital volume expansion to be spared the morbidity of a subcilliary or transconjunctival incision. Some degree of ectropion and scleral show may complicate as many as 20% of these incisions [28]. Radiologic criteria suggesting the need for orbital exploration include severe comminution or displacement of the orbital rim, displacement of greater than 50% of the orbital oor with prolapse of the orbital contents into the maxillary sinus, an orbital oor fracture greater than 2 cm2, and the combination of an inferior and medial wall fracture [26,28]. Based on these or similar criteria, approximately 30% to 44% of patients with ZMC fractures require an orbital incision [24,26]. A nal variable to consider in ZMC fractures is the status of the orbital apex. The orbital apex is the posterior portion of the orbit that contains the optic nerve and lies in close apposition to the internal carotid arteries and cavernous sinuses. Injury to this area may result in a number of serious injuries resulting from injury to the carotid arteries and to cranial nerves II, III, IV, V1, and VI [29]. The lateral wall of the orbital apex is formed by the greater wing of the sphenoid. This bone also contributes to the lateral orbital wall and articulates anteriorly with the zygoma. ZMC fractures may result in displacement of the greater wing of the sphenoid [29]. It is important to note whether this displacement occurs laterally or medially (into the orbital apex). The medial wall of the orbital apex is formed by contributions

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from the ethmoid and palatine bones and the body of the sphenoid bone. Fractures in these areas should also alert the radiologist to possible orbital apex involvement. Clinically relevant radiology reports: ZMC fractures 1. Recognize that a range of injuries from an isolated zygomatic arch fracture, to a classic tripod fracture, to a displaced, comminuted zygoma all represent fractures of the zygomaticomaxillary complex (ZMC). 2. Comment on the degree of displacement and comminution of the ZMC fracture. The more displaced and the more comminuted the involved bones are, the more complex the surgical repair with a need for wider surgical exposure and more points of xation. 3. Comment on the extent of orbital involvement. Fractures involving more than 50% of the orbital oor will likely require open reconstruction. 4. Identify whether the medial orbital wall (lamina papyracea) is involved. An isolated medial orbital wall fracture is generally not a cause of clinically signicant orbital volume loss; however, when found in combination with a oor fracture, it may require repair. 5. Comment on the involvement of the orbital apex and the direction of displacement of the lateral orbital wall. Nasal-orbital-ethmoid (NOE) fractures The nasal bones lie in close apposition to the ethmoid sinuses and the medial orbital walls. Low-force nasal trauma often remains limited to the nose, resulting in isolated nasal bone fractures. By contrast, high-force trauma is often transmitted through the nasal bones to also involve the underlying ethmoid sinuses and orbit [30]. Because of the intimate physical and functional relationship of the bony structures in this area, it is useful to consider the nasal-orbital-ethmoid region as a single unit when dealing with high-velocity facial trauma. Structures involved The nasal bones articulate superiorly with the nasal process of the frontal bone, laterally with the frontal process of the maxilla, and medially with one another. Just deep to the nasal bones lie the thin bones and air spaces of the ethmoid sinuses. The lateral boundary of the ethmoid sinuses is the medial orbital wall, which is formed by contributions from the frontal process of the maxilla as well as the lacrimal, frontal, ethmoid, sphenoid, and palatal bones [31]. As discussed in the preceding paragraph, high-velocity trauma to this area is generally transmitted to involve all of these bones to varying degrees. Evolutionarily, there is great advantage to the design of these thin bones and air-lled spaces: they form a low-resistance crumple zone that

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allows the traumatic force to be dissipated. The critical structures such as the brain and optic nerve lie within stronger bone behind this crumple zone and are thus relatively protected from injury [32]. Despite the protective nature of this design, signicant cosmetic and functional decits may arise from high-force NOE injury. Midface retrusion and nasal shortening occur as a result of the nasal bones telescoping inwards into the crumple zone. The medial canthal tendon (MCT) inserts on the anterior and posterior lacrimal crests and the frontal process of the maxilla. Telecanthus arises from displacement of the MCT fragment or disruption of the MCT from its bony insertions. Epiphora is another frequent complication of fractures in this area. The lacrimal drainage pathway extends from the lacrimal puncta at the medial canthus through the canaliculi, nasolacrimal sac, and nasolacrimal duct. These structures are closely related to the lacrimal and maxillary bones as well as to the medial canthal tendon; disruption of any of these related structures places the lacrimal drainage pathway in danger of obstruction [30,3335]. Persistent posttraumatic epiphora has been reported in 5% to 31% of patients with NOE fractures [35]. Damage may also occur to the frontonasal duct (see Frontal sinus fractures). Variables aecting treatment Status of the medial canthal tendon Markowitz and colleagues [36] classied NOE fractures based on the status of the medial canthal tendon and the degree of comminution of the fragment of bone to which it remains attached (Fig. 6). Type I injury occurs when fracture lines leave a central segment of bone with the medial canthal tendon attached (Fig. 7). These are the simplest to reconstruct, as this central segment can be plated to the surrounding facial bones. Type II fractures involve comminution of the central fragment, but the MCT remains rmly attached to a denable segment of bone. Type III fractures result in severe central fragment comminution with disruption of the MCT insertion sites. Type II and III injuries are the most dicult to repair, and require transnasal wiring (Fig. 8) of the medial canthal tendon-bearing bone fragments (Type II) or the MCT (Type III). Clinically, identication of these injuries is often dicult because of the presence of soft tissue edema. Thus, it is critically important to identify displacement or comminution of the medial canthal tendon insertion radiographically. Degree of bony injury: comminution and posterior displacement In addition to the degree of comminution of the central fragment, the degree of comminution of the surrounding nasal, maxillary, and orbital walls also plays an important role in the reconstructive plan. Severe comminution, posterior displacement, or loss of bone in the midface precludes reconstruction with plates and screws alone, and serves as an indication to

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Fig. 6. NOE fractures: Markowitz classication. (A) Type I fracture. The central fragment is large enough to allow direct plating of the fragment with attached bone. (B) Type II fracture. The central fragment is more comminuted that in Type I, but the MCT remains attached to the central fragment. (C) Type III fractures involve severe comminution of the central fragment with avulsion of the MCT. (From Markowitz BL, Manson PN, Sargent L, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classication and treatment. Plast Reconstr Surg 1991;87(5):84353; with permission.)

the surgeon that bone grafting will be necessary to reestablish adequate facial projection. Bone grafting is frequently necessary following NOE fractures to restore orbital volume and nasal projection (see Fig. 7) [36,37].

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Fig. 7. Markowitz Type I NOE fracture. (A) A 3D surface-rendered CT scan showing large noncomminuted central fragment (arrow). (B) Postoperative sagital CT scan showing cantilevered bone graft (arrow) in place to restore nasal projection. (C) Postoperative 3D surface rendering demonstrates plating of the central fragment (thin arrow) and cantilevered bone graft (thick arrow).

Associated injuries The cribiform plate forms the roof of the nasal cavity; as such, it is at risk for involvement in cases of NOE fracture. The nasofrontal duct may also be injured at the site of its outow in the anterior ethmoid sinuses. Finally, NOE fractures are associated with high-force trauma involving the medial orbital wall and have been associated with several ocular injuries, including hyphema, vitreous hemorrhage, lens dislocation, and globe rupture [30]. These associated injuries should be sought and commented upon in the radiology report. Clinically relevant radiology reports: NOE fractures 1. Recognize that a nasal bone fracture in combination with a fracture of the medial orbital wall and frontal process of the maxilla represents

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Fig. 8. NOE fracture and repair. (A) Axial CT through the NOE shows a left Type II (small fracture fragment, but still attached to the canthal ligament) fracture (arrow). (B) Postoperative frontal radiograph shows a cerclage wire (arrows) attached to both NOE fragments to hold them into position.

2.

3.

4.

5.

disruption of a facial unit known as the nasal-orbital-ethmoid (NOE) complex. Indicate whether the central fragment of the medial orbital wall (to which the medial canthal tendon attaches) is displaced and/or comminuted. Comment on the degree of displacement of the nasal root (nasal bridge), either posteriorly into the ethmoids or superiorly into the anterior cranial fossa. Comment on the degree of comminution of the nasal bones, frontal processes of the maxilla, and nasal processes of the frontal bones, as comminution in these areas may require the surgeon to plan for bone grafting. Comment on the presence or absence of commonly associated injuries, including cribiform plate fracture, nasofrontal duct injury, and ocular injury.

Orbital wall and oor fractures There are two main types of orbital fractures. The rst type occurs when one or more of the bony walls of the orbit are fractured. The inferior orbital rim, in particular, is frequently fractured and displaced inward into the orbit. The displaced bone directly impacts the more delicate bones of the orbital walls and orbital oor, resulting in secondary fractures in these regions. Because the inferior orbital rim is derived largely from the zygomatic bone, fractures of the zygoma or its attachments that result in displacement of the zygoma frequently cause secondary fractures of the orbital walls and oor [38]. The second type of orbital fracture is what is

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commonly known as an orbital blowout fracture. In this type of fracture, the orbital rim remains intact, but the force of impact is transmitted to the delicate bones of the orbital oor, roof, and medial wall (Fig. 9), causing fractures in these bones without disrupting the continuity of the stronger inferior, lateral, and superior orbital rims. Structures involved The orbit is shaped like a cone, with the apex posteriorly. The greatest diameter is not at the inferior orbital rim, however, but approximately 15 mm posterior to it, at a point where the medial wall, roof, and oor of the orbit are all concave relative to each other [39]. Posterior and posteromedially to this, the orbital oor becomes convex. This conguration has important implications for reconstruction of orbital fractures, as failure to reconstruct the convex portion (including the medial orbital wall) is one of the common causes of postoperative enophthalmos [40]. Variables aecting treatment The primary determination to make when assessing the CT scan is whether the orbital fracture is an isolated blowout fracture or part of a larger fracture pattern. Orbital fractures occur in combination not only with ZMC fractures but also with Le Fort and NOE fractures. If the orbital fractures consist only of fractures of the orbital oor, roof, or medial wall without fracture of the rm orbital rims, then the treatment algorithm for orbital blowout fractures applies. Orbital fractures occurring along with other fracture patterns are more likely to be the result of a high-force injury, and frequently require a more extensive surgical repair.

Fig. 9. Orbital blowout fractures. Although orbital oor fractures (arrow, A and B) are the most common type of blowout fracture, medial wall fractures (arrowheads, A) and superior wall fractures (arrow, B) may also be seen.

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There are three main indications to treat isolated orbital wall fractures. The rst is entrapment of any of the extraocular muscles. Entrapment of the muscle can cause ischemic damage, and permanent dysfunction can occur if the fracture is not reduced and the muscle released expeditiously [41,42]. Entrapment is diagnosed on clinical exam and cannot be directly assessed on CT. However, herniation of the extraocular muscles beyond the bony margins of the orbit is suggestive of entrapment and should be sought on CT. The radiologic diagnosis of herniation may be especially difcult in children, as the more pliable bone may result in trapdoor fractures (Fig. 10). These fractures result when the bone of the inferior orbit is displaced inferiorly and forms a greenstick fracture. The pliable bones

Fig. 10. Orbital trapdoor fracture. (A) The small mass of soft tissue at the maxillary sinus roof could be confused with blood, but it actually represents a herniated and incarcerated right inferior rectus muscle. Note the loss of the inferior rectus muscle shadow (compare with right eye, arrowhead). (B) The fracture is subtle on bone windows because the displaced bone has snapped back into place. (C) Postoperative coronal CT scan showing reduction of the fracture with reappearance of the inferior rectus muscle shadow within the orbit.

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then snap rapidly back into to a near-normal position, but the inferior rectus muscle can become trapped in the fracture line in the process. This may occur without any evidence of bone loss in the orbital oor or blood or soft tissue in the maxillary sinus. CT ndings in trapdoor-type fractures can be quite subtle, and may be overlooked if they are not actively sought [41]. One characteristic nding in such fractures is the loss of the inferior rectus muscle in the orbit (see Fig. 10). Coronal reformats are critical in the evaluation of the orbital oor. The second indication for treatment is to prevent postoperative globe malposition and its resulting complications of diplopia or enophthalmos. Because of the diuse soft tissue edema associated with facial fractures, it can be dicult to assess in the acute setting whether or not a patients fractures will result in globe malposition after the swelling has resolved. Although there is no set rule, many surgeons believe that orbital reconstruction is necessary in the following situations: (1) early clinical enophthalmos, before the soft tissue edema has dissipated, (2) displacement of greater than 50% of the orbital oor (Fig. 11), (3) orbital volume change greater than 1.5 mL (5% of normal orbital volume), and (4) signicant fat or soft tissue displacement [3943]. The third indication for surgery of the orbit is when the force of the impact is so severe that the lateral orbital wall (orbital plate of the sphenoid bone) impacts into the orbital apex or middle cranial fossa (Fig. 12). In such cases, surgery may be indicated for decompression of neural structures [39]. The surgeon should be cautioned, however, that surgical intervention may worsen a tenuous situation, (ie, secondary to intraoperative compression/

Fig. 11. Large orbital oor fracture. Coronal reformatted CT shows a fracture encompassing almost the entire orbital oor (arrowheads). Fractures of greater than 50% of the orbital oor are usually repaired surgically.

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Fig. 12. High-impact orbital fracture. The orbital oor fracture on this axial CT extends from the inferior orbital rim (arrow) all the way to the apex (arrowhead), where it involves the lateral wall of the optic canal. Extension to the rim or apex indicates high traumatic force, and is an important factor in surgical repair.

manipulation of the orbital apex), and preoperative consultation with an ophthalmologist is recommended. Clinically-relevant radiology reports: Orbital fractures 1. Note the presence or absence of extraocular muscle herniation. Muscle entrapment is a surgical emergency, so when herniation is identied on CT, the surgeon should be notied immediately. 2. Determine whether the orbital fracture is an isolated blowout fracture, or part of a larger fracture pattern (ZMC, NOE, Le Fort). 3. Identify which orbital walls are fractured: when one wall is fractured, look carefully at the other walls. 4. Estimate the size of each of the fractures (ie, in cm2 or in percentage of oor/walls) and the degree of displacement of fat and soft tissues. Le Fort fractures More than 100 years ago, Rene Le Fort devised a classication system for midface fractures. This classication scheme is based on his nding that blunt trauma tends to cause fractures along three particular lines of weakness inherent in the design of the facial skeleton [38]. Le Fort based his system on his observation of experimental fractures made in cadavers. Fractures occurring in 21st-century, real-life situations (in particular, high-velocity motor vehicle accidents) often deviate from this classication system, and pure Le Fort fractures are rare. Nevertheless, the Le Fort

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classication system is widely known, and it provides a method for concise communication of fracture patterns between clinicians and radiologists. Structures involved There are three types of Le Fort fractures (Fig. 13). Each Le Fort level describes not an isolated fracture, but rather a pattern of fractures involving multiple facial bones. The most consistent and uniting feature of the Le Fort fractures is the presence of bilateral pterygoid fractures. Pterygoid fractures are found in all three classes of Le Fort fractures, and are the key to establishing the diagnosis [44]. If a CT reveals bilateral pterygoid fractures, a Le Fort fracture should be suspected. Conversely, if the CT scan does not reveal pterygoid fractures, the Le Fort fractures can be excluded [44]. The Le Fort I fracture is a horizontal fracture through the maxilla, cephalic to the maxillary dentition. Bones fractured in a Le Fort I pattern include the lower nasal septum, the inferior portion of the piriform apertures, the canine fossae, both zygomaticomaxillary buttresses, the posterior maxillary walls, and the pterygoid plates. The Le Fort II fracture is often described as being pyramidal in shape [44]. It traverses the nasofrontal junction and extends laterally across the medial orbital wall, orbital oor, infraorbital rim, and then through the zygomaticomaxillary suture line. It also proceeds posteriorly through the nasal septum and pterygoid plates. The Le Fort III fracture is a complete craniofacial separation, resulting in separation of the facial bones from the cranium along the line of the nasofrontal and zygomaticofrontal suture lines. As in Le Fort II fractures, the fracture transverses the nasofrontal junction and extends laterally through the orbit; however, Le Fort III fractures involve not only the medial and inferior orbital walls but also the lateral orbital wall, zygomaticofrontal suture line, and zygomatic arch. As with the other Le Fort fractures, the fracture line also extends posteriorly through the nasal septum and pterygoid plates. Each Le Fort fracture pattern has at least one unique component fracture that is easily recognizable and separates it from the other Le Fort fractures [44]. Rhea and Novelline recently used these unique identifying fractures to design a simple method for identifying and classifying facial fractures [44]. Only the Le Fort I fracture involves the lateral aspect of the piriform aperature. Only the Le Fort II fracture involves the inferior orbital rim and zygomaticomaxillary suture line. Finally, only the Le Fort III fracture involves the zygomatic arch and the lateral orbital wall. When midfacial fractures are present and a Le Fort fracture pattern is suspected, the authors recommend rst looking at the pterygoid plates. If there is a bilateral pterygoid fracture, a Le Fort fracture is likely present. The next step is to inspect the three dening fractures discussed above: the lateral piriform aperatures, the inferior orbital rim, and the zygomatic arch. The presence or absence of each of these fractures determines whether a fracture of that type is present

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or absent [44]. For example, the absence of a lateral piriform fracture rules out a Le Fort I; the presence of a zygomatic arch fracture makes is likely that a Le Fort III fracture is present. The nal step is then to look systematically for fractures of the other bones that are involved in the Le Fort levels. This is important because it is possible to have a Le Fort fracture on one side and an isolated ZMC or NOE fracture on the other side. The presence of the key indicator fractures does not denitively diagnose the Le Fort level; instead, it serves to alert the radiologist to the high likelihood of a particular Le Fort fracture. The other associated fractures must still be identied. Finally, it is possible to have more than one Le Fort level on a single side of the facial skeleton [44]. For this reason, all three key indicator fractures must be examined, allowing each Le Fort level to be ruled in or ruled out, regardless of whether there is a coexisting Le Fort fracture of a dierent level [44]. Variables aecting treatment Le Fort fractures result in both a cosmetic and a functional decit. As discussed above, the facial skeleton is formed by a combination of the relatively strong bones forming the midfacial buttresses, and the more fragile bones containing air-lled sinuses that lie deep to the buttresses (see Fig. 1). Le Fort fractures generally disrupt both. These fractures are caused by forces strong enough to break the buttresses, which then collapse internally and result in the secondary fracture of the more fragile internal bones. The result, as with NOE fractures, is retrusion of the central midface. In addition, Le Fort fractures may result in a loss of the vertical height of the face as a result of interruption of the vertical buttresses. Finally, the force required to cause a Le Fort fracture generally results in other facial bone fractures, and these add to the diculty of the surgical repair. Fractures of the hard palate or dentoalveolar units are frequently associated with Le Fort fractures (Fig. 14). The presence of such fractures is clinically important, as they further disrupt the patients occlusion, adding signicantly to the complexity of fracture repair. To achieve normal midface projection, normal occlusion must be restored before anchoring the upper midface to the maxilla. Similarly, the presence of a coexisting mandibular fracture will aect the occlusion. For Le Fort II and III fractures, associated ZMC, NOE, or frontal sinus fractures must be recognized. The frontal bar must be reconstructed before the midface can be resuspended to it. The goals of treatment are thus to restore occlusion, facial height, and facial projection. Knowledge of the Le Fort levels involved on each side is crucial when making the operative plan, as the surgical access incision depends greatly on the level of fracture. Le Fort Level I fractures may be accessed via a gingivo-buccal sulcus incision, whereas Le Fort II and III fractures may require a coronal and possibly an orbital access incision such as the transconjunctival or subcillary approach [45]. The nal consideration is the

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Fig. 14. Axial CT scan demonstrating oblique palatal fracture (arrows) in a patient with bilateral Le Fort fractures. The presence of associated palatal fracture adds to the diculty of establishing dental occlusion before fracture reduction.

degree of comminution of the involved bones. The buttresses must be recreated to restore facial height and projection. If the buttresses are severely comminuted, they may be inadequate for this function, and bone grafting may be necessary. A nal consideration, as with other high-energy fractures, is the orbital apex. Many Le Fort fractures extend to the anterior cranial base, and in doing so the fracture lines traverse the orbital apex. Although not described by Le Fort, some authors refer to this type of fracture as a Le Fort IV fracture [29,45]. Le Fort fractures are frequently reduced with disimpaction forceps and a great deal of manual force. Fracture lines through the orbital apex and close to the carotid canal must be identied on preoperative CT scan to alert the surgeon to use a more gentle reduction technique to avoid disrupting the fractured bones in these critical areas [29].

;
Fig. 13. Le Fort fractures. (A) Schematic of the Le Fort fracture patterns. (From Linnau KF, Stanley RB Jr, Hallam DK, et al. Imaging of high-energy midfacial trauma: what the surgeon needs to know. Eur J Radiol 2003;48:1732; with permission.) (B) Axial CT scan demonstrating fractures of the bilateral pterygoid plates (arrows). Presence of bilateral pterygoid plate fractures is strongly suggestive of the presence of Le Fort fractures. (C) Coronal reformat of a Le Fort I fracture shows fracture lines extending though the walls of the maxillary antrum (arrows) and across the nasal septum, without orbital involvement. (D) Coronal reformat of a LeFort II fracture shows fracture lines through the maxillary antrum (arrow), and through the inferior and medial walls of the orbital (arrowheads), as well as the nasal bridge. (E) Coronal reformat of a Le Fort III fracture shows fractures though the zygomatic arch and lateral orbital walls (arrow), as well as the orbital roofs (arrowhead).

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Clinically relevant radiology reports: Le Fort fractures 1. Indicate which Le Fort levels are involved. Le Fort levels may dier between the two sides of the face, and fractures may occur through more than one Le Fort level on the same side of the face. 2. Other facial fracture patterns such as NOE, frontal sinus, and ZMC fractures frequently occur in association with Le Fort fracture patterns, and should be noted. 3. Fractures of the hard palate, maxillary dentoalveolar units, and mandible will aect occlusion and thus aect the repair; these injuries should be specically sought.

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