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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.
Males are affected more commonly than females, and facial fractures are most common in the third decade, i.e. 20-30 years 4.
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 8.
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 4.
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 5:
- nasoseptal fractures
- naso-orbitoethmoid (NOE) complex fractures
- orbital fractures
- zygomaticomaxillary complex (ZMC) fractures
- occlusion-bearing maxillary fractures
Beyond the midface, other clinically-significant fractures of the facial area include:
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 6,7. McGrigor-Campbell and Dolan's lines have been described in the assessment of plain radiographs for facial fractures.
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 6,7. To a lesser extent, CT also provides an evaluation of the facial soft tissues, although has poor sensitivity for cartilaginous injuries 5.
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 5.
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 5. Make sure to highlight injuries most likely to have surgical or cosmetic implications 5:
- 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
- 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
- 1. Winegar BA, Murillo H, Tantiwongkosi B. Spectrum of critical imaging findings in complex facial skeletal trauma. Radiographics. 2013;33 (1): 3-19. doi:10.1148/rg.331125080 - Pubmed citation
- 2. Hopper RA, Salemy S, Sze RW. Diagnosis of midface fractures with CT: what the surgeon needs to know. Radiographics. 2006;26 (3): 783-93. doi:10.1148/rg.263045710 - Pubmed citation
- 3. Rhea JT, Novelline RA. How to simplify the CT diagnosis of Le Fort fractures. AJR Am J Roentgenol. 2005;184 (5): 1700-5. doi:10.2214/ajr.184.5.01841700 - Pubmed citation
- 4. Hwang K, You SH. Analysis of facial bone fractures: An 11-year study of 2,094 patients. Indian J Plast Surg. 2010;43 (1): 42-8. doi:10.4103/0970-0358.63959 - Free text at pubmed - Pubmed citation
- 5. Dreizin D, Nam AJ, Diaconu SC, Bernstein MP, Bodanapally UK, Munera F. Multidetector CT of Midfacial Fractures: Classification Systems, Principles of Reduction, and Common Complications. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (1): 248-274. doi:10.1148/rg.2018170074 - Pubmed
- 6. Shetty VS, Reis MN, Aulino JM, Berger KL, et al. ACR Appropriateness Criteria® Head Trauma. Available from American College of Radiology. Accessed Jun 13, 2018.
- 7. Kennedy TA, Corey AS, Policeni B, Agarwal V, et al. ACR Appropriateness Criteria® Orbits, Vision, and Visual Loss. Available from American College of Radiology. Accessed Jun 13, 2018.
- 8. Alessandrino Francesco, Abhishek Keraliya and Jordan Lebovic et al. "Intimate Partner Violence: A Primer for Radiologists to Make the “Invisible” Visible". RadioGraphics 40, no. 7 (2020): 2080-2097. . doi:10.1148/rg.2020200010.