Clinical features vary with the severity of the trauma and the time between trauma and presentation. The force may be transmitted along the orbital rim or through the orbit, compressing the globe, which pushes into the orbital floor ('blowout' fracture). This usually follows a blow from an object >5 cm (eg, a tennis ball). 3D reconstruction is helpful if surgical treatment is planned. CT scanning is the gold standard imaging modality.The coronoid processes which should be equidistant from the maxillary line bilaterally.An 'elephant's trunk' - follow the zygomatic line laterally and the maxillary line medially.The sinus outline - any opacification or fluid level in the maxillary sinus is suggestive of a fracture.The orbital outline - the droplet sign shows soft tissue prolapsing into the maxillary sinus in an orbital floor fracture.Interpretation may be difficult - systematically check for : A plain X-ray of the skull is basic - standard views are facial, occipitomental and submento-vertical.Muscle entrapment can also cause nausea and vomiting. Note that extraocular muscle entrapment can cause an oculo-cardiac reflex leading to collapse. Other injury - look for and exclude potential cervical or head injury.Check also for impairment of sensation below the eye. Where the eye is closed by swelling, check for the integrity of the optic nerve by asking the patient to confirm presence/absence of light over the closed lid. Extent of any subconjunctival haemorrhage.Particular points to note (in both eyes) include: Examine the lids (not forgetting the tear drainage ducts) and the globe as well as the function of the eye - see the separate Examination of the Eye article. Ocular injury - eye injury is very common in midface trauma.Note any surgical emphysema, oedema or haemorrhage. Look for points of tenderness on gentle palpation. General points - look at the contour, note areas of bruising and obvious abrasions or lacerations.When examining these patients, you need to look for direct damage, associated damage (eg, to structures immediately adjacent to the area, such as the eye) and more peripheral damage (eg, head injury as a result of falling backwards following a blow). The underlying bony injury and or globe injury are often more serious than initial examination suggests. Orbital injuries are often missed or misdiagnosed. If this is part of a multiple trauma picture, go through the usual trauma pathway first before focusing on the area of injury(ies). NB: if this is an alleged assault or an injury at the workplace, make detailed notes documenting timing and circumstances of injury. Severe pain may indicate retrobulbar haemorrhage - especially if associated with visual loss or ophthalmoplegia. The mucosa of the maxillary sinus may be lacerated and cause epistaxis on that side. Other symptoms - trismus is spasm of the masseter and it makes chewing difficult and painful.Visual symptoms - diplopia can occur due to entrapment of a muscle, neural injury or a haematoma in an external ocular muscle.Aetiology is usually blunt trauma to the cheek, such as involved in:Īssessment of potential fractures History The group at highest risk is young males. Zygomatic arch fracturesĪfter the nasal bone, the zygoma is the second most common bone of the face to be fractured. The incidence of orbital fractures peaks in a bimodal fashion, at 10-40 years and again at 70 years. Males are at higher risk than women of most kinds of trauma, including orbital injuries. Children are more likely to sustain skull fractures and brain injuries than facial fractures. įacial fractures are rare before the age of 5 years. The incidence and causes of maxillofacial trauma and facial fractures vary widely in different regions of the world due to social, economic and cultural consequences, awareness of traffic regulations and alcohol consumption. Maxillofacial fractures can have various causes, including traffic accidents, falls, assaults and sports injuries. Displacement of the zygomatico-frontal suture.The strong central part of the bone usually remains intact and the force is transmitted to the three buttresses, individually or simultaneously (a 'tripod' fracture) resulting in: The bones are either fractured or dislocated. The malar complex is also commonly fractured in isolation by a blow to that area. The most common orbital injury is a 'blowout' fracture, usually involving the orbital floor ± the medial wall.
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