Facial fractures

Facial fractures are commonly caused by blunt or penetrating trauma at moderate or high levels of force. Such injuries may be sustained during a fall, physical assault, motor vehicle collision, or gunshot wound. The facial bones are thin and relatively fragile making them susceptible to injury.

Epidemiology

Males are affected more commonly than females, and facial fractures are most common in the third decade, i.e. 20-30 years .

Intimate partner violence should be considered in patients where the clinical details do not match the fracture, or the injury occurs in an intimate setting .

Pathology

The extent and pattern of soft tissue and osseous facial injuries varies according energy of impact. Isolated fracture is most common with lower energy trauma, whereas high energy blunt and penetrating trauma results in more complex, less predictable injury pattern.

The most commonly fractured facial bones (in isolation) are the nasal bones, followed by the mandible and the bony orbit. Fractures involving more than one bone most commonly affect the orbital floor and zygomaticomaxillary complex .

Types

Facial fractures have been categorized according to multiple schemas, most famously according to a simplified three-tier Le Fort classification for complex midface fractures. The concept of 'facial buttresses' has also been used to elucidate structurally-meaningful skeletal struts which play important in facial integrity.

More recently, advances in surgical technique enable surgeons to consider reduction, stabilization, and reconstruction of complex midfacial fractures according to five midface subunits :

• nasoseptal fractures
• naso-orbitoethmoid (NOE) complex fractures
• orbital fractures
• zygomaticomaxillary complex (ZMC) fractures
  • isolated zygomatic arch fractures
• occlusion-bearing maxillary fractures
  • alveolar process fractures

Beyond the midface, other clinically-significant fractures of the facial area include:

• frontal sinus fracture
• paranasal sinus fractures
• mandibular fracture

Radiographic features

Plain radiograph

Plain radiograph has poor sensitivity for detection of facial fractures. It should not play a role in the diagnosis of head trauma, except in limited circumstances such as detection of a radiodense foreign body . McGrigor-Campbell and Dolan's lines have been described in the assessment of plain radiographs for facial fractures.

CT

CT is the standard of care for evaluation of suspected facial fracture because it is readily available, rapidly acquired, and highly accurate in detecting even subtle fractures. Importantly, it is also used to simultaneously evaluate for acute intracranial pathology which may be more urgent . To a lesser extent, CT also provides an evaluation of the facial soft tissues, although has poor sensitivity for cartilaginous injuries .

Although 3D volumetric reconstructions are valuable for surgical planning and assessing global morphology and facial symmetry, they are susceptible to volume-averaging. Thin structures (e.g. medial wall and floor of orbit) should not be evaluated by volumetric reconstruction and must be assessed using fine-resolution axial and coronal reconstructions .

Radiology report

Although it is the radiologist's role to detect and accurately diagnose facial fractures on imaging, it is equally important to communicate the findings in a meaningful and useful way within the radiology report. A high-quality report should reflect an understanding of the clinically-important features which may impact management.

In the setting of complex injury, a report listing each fracture and a Le Fort fracture categorization may be less helpful. Instead, consider describing fractures according to surgically-relevant midface subunits . Make sure to highlight injuries most likely to have surgical or cosmetic implications :

• even minor injuries to nasoseptal structures
  • the CT appearance may belie presence or degree of cartilaginous injury (strongly associated with late deformity)
• findings associated with late enophthalmos
  • see orbital blowout fracture
• compromise of the zygomaticosphenoid suture
  • important in anticipating overall alignment and orbital volume change
• fractures affecting dental occlusion (maxillary-mandibular tooth alignment)
  • occlusion-bearing maxillary fractures, mandibular fractures
  • as little as 2-3 mm of malocclusion is considered significant