16 - Malar fractures

Question 1

What are the classifications of maxillofacial fractures?

Answer 1

• nasoethmoidal
• lateral middle third (zygoma)
• central middle third
• mandibular

Question 2

What are the types of central middle third fractures?

Answer 2

• nasal
• unilateral maxillary fracture
• le fort 1
• le fort 2
• le fort 3

Question 3

What structure are at risk if the anterior wall of the orbit is fractured?

Answer 3

• eyelids
• cornea
• sclera

Question 4

What structure are at risk if the medial wall of the orbit is fractured?

Answer 4

• medial rectus muscle
• medial canthal ligament
• nose
• lacrimal duct and sac
• ethmoid sinus
• cribriform plate

Question 5

What structure are at risk if the roof of the orbit is fractured?

Answer 5

• superior orbital fissure and nerve
• occulomotor nerve III
• trochlear nerve IV
• abducent nerve VI
• branches of ophthalmic nerve
• ophthalmic veins
• dura in frontal lobe

Question 6

What structures are at risk if the floor of the orbit is fractured?

Answer 6

• infraorbital nerve
• infraorbital vein
• infraorbital artery
• inferior rectus and oblique muscle

Question 7

What is the order of the clinical exam of the maxillofacial region?

Answer 7

• soft tissue
• nerves
• skeleton
• dentition

Question 8

What are the clinical signs of malar fracture?

Answer 8

• periorbital bruising and swelling
• subconjunctival ecchymoses (bleed)
• sensory deficit of infraorbital nerve
• diplopia
• subcutaneous emphysema
• epistaxis
• step deformity
• eye can appear lower if eye sinks in orbit
• trismus

Question 9

Why does malar fracture cause diplopia?

Answer 9

• double vision when looking to side
• direct trauma to eye causes pressure
• eye cannot move freely as it sinks into orbit

Question 10

Why does malar fracture cause trismus?

Answer 10

Mechanical lock of coronoid process against zygoma

Question 11

What is the initial care of malar fracture?

Answer 11

• exclude ocular injury
• prophylactic antibiotics (compound fracture)
• avoid nose blowing

Question 12

What is the definitive management of malar fracture?

Answer 12

• review when swelling subsided
• further imaging
• closed reduction ± fixation
• open reduction + internal fixation

Question 13

Define closed reduction.

Answer 13

• no surgical incision
• reduced by palpation and appearance
• fixation can be external (ie cast)

Question 14

Define open reduction.

Answer 14

• surgical incision to visualise fracture
• internal fixation (screws and plates) used to hold fracture in place

Question 15

What open reduction options are available for malar fracture?

Answer 15

• intra-oral incision
• local facial incision
• coronal flap exposure

Question 16

What structure are at risk if the lateral wall of the orbit is fractured?

Answer 16

• lateral canthal ligament and muscle
• V1
• lateral rectus muscle
• middle cranial fossa
• dura and temporal lobe of brain

Question 17

What symptoms are associated with fracture to the floor of the orbit?

Answer 17

• sunken eye
• diplopia
• infraorbital anaesthesia
• antro-orbital communication
• naso-lacrimal duct damage

Question 18

What symptoms are associated with fracture to the lateral wall of the orbit?

Answer 18

• sunken eye
• inward displacement
• lateral canthal displacement
• lateral rectus palsy

Question 19

What symptoms are associated with fracture to the medial wall of the orbit?

Answer 19

• nasal shortening
• bridge depression
• diplopia
• CSF leak
• eyes drifting apart

Question 20

What symptoms are associated with injury to the orbit?

Answer 20

• periorbital haematoma
• proptosis
• swelling
• sunken eye

Question 21

What symptoms are associated with fracture to the roof of the orbit?

Answer 21

• dural tear or brain damage
• CSF leak
• trochlear damage
• diplopia
• frontal anaesthesia
• sunken eye

Question 22

What symptoms are associated with fracture to the apex of the orbit?

Answer 22

Blindness