Basim Ahamed

2016 batch
1. Nasal bones and Septum
2. Naso-orbital fractures
3. Fractures of zygoma (tripod fracture)
4. Fractures of zygomatic arch
5. Fractures of orbital floor
6. Fractures of maxilla
 Most common fracture on face
 Types:
a) Depressed- caused due to frontal blow. Severe
frontal blow will cause“open-book fracture” in which
nasal septum is collapsed and nasal bone splayed
out.
b) Angulated- A lateral blow may cause unilateral
depression of nasal bone on the same side or may
fracture both the nasal bones and the septum with
deviation of nasal bridge.
Clinical features
i. Swelling of nose.
ii. Periorbital ecchymosis
iii. Tenderness.
iv. Nasal deformity.
v. Crepitus and mobility of fractured
fragments.
vi. Epistaxis.
vii. Nasal obstruction
viii. Lacerations of the nasal skin with exposure
of nasal bones
Diagnosis
 Diagnosis is best made on physical
examination. X-rays are taken.
 X-rays should include Waters’ view, right and
left lateral views and occlusal view.
Treatment
 Simple fractures without displacement need no
treatment;
 others may require closed or open reduction
 Closed reduction.
Depressed fractures of nasal bones sustained by either frontal
or lateral blow can be reduced by a straight blunt elevator guided
by digital manipulation from outside.
Laterally, displaced nasal bridge can be reduced by firm
digital pressure in the opposite direction. Septal
haematoma, if present, must be drained.
 Open reduction.
Indicated if closed method fails. Healed nasal deformities
resulting from nasal trauma can be corrected by rhinoplasty or
septorhinoplasty.
 Direct force over the nasion fractures nasal bones and
displaces them posteriorly.
 Perpendicular plate of ethmoid, ethmoidal air cells and
medial orbital wall are fractured and driven posteriorly.
 Clinical features
◦ Pug nose
◦ Telecanthus
◦ Periorbital ecchymosis
◦ Orbital hematoma
◦ CSF leakage
◦ Eyeball displacement
 Diagnosis
◦ CT
 Treatment
◦ 1. Closed reduction. In uncomplicated
cases, fracture is reduced with Asch’s
forceps and stabilized by a wire passed
through fractured bony fragments and
septum and then tied over the lead plates.
Intranasal packing is given. Splinting is
kept for 10 days or so.
◦ 2. Open reduction. This is required in
cases with extensive comminution of nasal
and orbital bones, and those complicated
by other injuries to lacrimal apparatus,
medial canthal ligaments, frontal sinus,
etc.
 second most frequently fractured bone.
 Lower segment of zygoma is pushed medially
and posteriorly resulting in flattening of the
malar prominence and a step deformity at the
infraorbital margin.
 Orbital contents may herniate into the
maxillary sinus.
Clinical features
 Flattening of malar prominence.
 Step deformity of infraorbital margin.
 Anaesthesia in the distribution of infraorbital
nerve.
 Trismus, due to depression of zygoma on the
underlying coronoid process.
 Oblique palpebral fissure, due to the
displacement of lateral palpebral ligament.
 Restricted ocular movements, due to entrapment
of inferior rectus muscle. It may cause diplopia.
 Periorbital emphysema
 Diagnosis
◦ X rays
◦ CT
◦ Waters’ or exaggerated Waters’ view shows the
fracture and displacement the best.
 Treatment
◦ Open reduction and internal wire fixation
◦ Fracture is exposed at the frontozygomatic
suture through lateral brow incision and reduced
by passing an elevator behind the zygoma.
◦ Wire fixation is done at frontozygomatic suture
and infraorbital margin. The latter is exposed by
a separate incision in the lower lid.
 Zygomatic arch generally breaks into two
fragments which get depressed.
 There are three fracture lines, one at each
end and third in the centre of the arch.
 Clinical features
◦ depression in the area of zygomatic arch.
◦ local pain aggravated by talking and chewing
◦ Trismus
 Diagnosis
◦ Arch fractures are best seen on submentovertical
view of the skull. Waters’ view is also taken.
 Treatment
◦ A vertical incision is made in the hair-bearing area
above or in front of the ear, cutting through
temporal fascia.
◦ An elevator is passed deep to temporal fascia and
carried under the depressed bony fragments which
are then reduced.
 Zygomatic and Le Fort II maxillary fractures are
always accompanied by fractures of orbital
floor.
 Isolated fractures, when a large blunt object
strikes the globes, are called “blow out
fractures.”
 Herniation of orbital contents into sinus msy
occur.
 Clinical features
◦ Ecchymosis of lid, conjunctiva and sclera.
◦ Enophthalmos with inferior displacement of the
eyeball.
◦ Diplopia,
◦ Hypoaesthesia or anaesthesia of cheek and upper lip,
if infraorbital nerve is involved.
 Diagnosis
◦ Waters’ view shows a convex opacity bulging into the
antrum from above (tear-drop opacity).
◦ CT scans
◦ Entrapment of inferior rectus and inferior oblique
muscles is diagnosed by asking the patient to look
up and down.
 Treatment
◦ Orbital floor fractures can be satisfactorily reduced
by a finger passed into the antrum through a
transantral approach.
◦ pack can be kept in the antrum to support the
fragments.
◦ Infraorbital approach, through a skin crease of the
lower lid, can also be used
◦ Bone graft can be used for badly comminuted
fractures.
◦ Silicon or teflon sheets have also been used
 three types:
i. Le Fort I (transverse) fracture runs above and
parallel to the palate.
ii. Le Fort II (pyramidal) fracture passes through the
root of nose, lacrimal bone, floor of orbit, upper
part of maxillary sinus and pterygoid plates.
iii. Le Fort III (craniofacial dysjunction). There is
complete separation of facial bones from the
cranial bones. The fracture line passes through
root of nose, ethmofrontal junction, superior
orbital fissure, lateral wall of orbit,
frontozygomatic and temporozygomatic sutures
and the upper part of pterygoid plates.
 Clinical features
1. Malocclusion of teeth with anterior open bite.
2. Elongation of midface.
3. Mobility in the maxilla.
4. CSF rhinorrhoea.
 Diagnosis
◦ X-rays, helpful in diagnosis of maxillary fractures are
Waters’ view, posteroanterior view, lateral view and the
CT scans.
 Treatment
1) Interdental wiring.
2) Intermaxillary wiring using arch bars.
3) Open reduction and interosseous wiring as in
zygomatic fractures.
4) Wire slings from frontal bone, zygoma or infraorbital
rim to the teeth or arch bars