Facial Trauma
Overview
Maxillofacial trauma encompasses injuries to the facial skeleton and soft tissues. Thin-section CT with multiplanar reformation (MPR) is the gold standard for evaluation, providing complete information on fracture patterns, ocular injury, and associated brain involvement.
Le Fort Classification
All Le Fort fractures involve bilateral pterygoid plate fractures — this is the sine qua non. They are classified by the level of midfacial separation:
- Le Fort I (Floating Palate): Horizontal fracture separating the alveolar process from the rest of the maxilla.
- Le Fort II (Pyramidal): Fracture through the nasal bones, medial orbital walls, and infraorbital rims, separating the central midface from the lateral orbits and zygoma.
- Le Fort III (Craniofacial Dysjunction): Complete separation of the entire midface from the cranial base through the zygomatic arches and lateral orbital walls.
Orbital Blow-Out Fractures
Direct impact raises intraorbital pressure, fracturing the thinnest orbital wall — typically the floor (into the maxillary sinus) or the medial wall (into the ethmoid air cells). CT sign: 'teardrop' opacity in the roof of the maxillary sinus = herniated orbital fat or inferior rectus.
WarningInferior Rectus Entrapment
Inferior rectus entrapment in the floor fracture causes restricted upward gaze and vertical diplopia. In children, the 'trapdoor' fracture may show no significant bony displacement yet can cause ischaemic muscle necrosis within hours — urgent surgical exploration is required.
High Yield Facts
LightbulbFRCR / MD Prep Pearl
ZMC (Zygomaticomaxillary Complex / tripod) fractures are the most common midfacial fractures. Fractures occur at 4 articulations: zygomatic arch, zygomaticofrontal suture, zygomaticosphenoidal suture, and infraorbital rim. Always assess the orbital floor in ZMC fractures on axial and coronal CT.