Presentation
One story fall
Patient Data
- frontobasal fractures, comminuted and displaced, involving both medial (cribriform-ethmoid) and lateral (orbital roof) regions and extending in a sagittal plane posteriorly to the central skull base (planum sphenoidale, sella turcica, and clivus)
- bilateral frontal sinus fractures, comminuted, involving anterior and posterior tables and frontal recess
- left Le Fort III fracture, displaced, including lateral orbital wall component
- bilateral Le Fort II fractures, displaced, including medial orbital wall and orbital floor components
- bilateral Le Fort I fractures, displaced
- nasoseptal fractures, comminuted
- left parasagittal palate fracture
- mandibular fractures, right parasymphyseal and right ramus/subcondylar, displaced
- left temporomandibular joint dislocation
- subarachnoid hemorrhage and moderate volume pneumocephalus, most concentrated in the frontobasal region with trace redistribution elsewhere and refluxed into the right lateral ventricle
- frontal calvarial fractures, comminuted and inwardly displaced, with linear extension into the left parietal bone
- small bifrontal and left parietal extraaxial (subdural or epidural) hematomas
- likely small areas of parenchymal contusion in the bilateral frontal lobes
- occlusion of the left ophthalmic artery proximally with reconstitution in the orbit, concerning for compression at the orbital apex from adjacent fractures and hematomas and/or vascular injury
- no other areas concerning for traumatic large arterial injury in the head and neck
- no dural venous sinus thrombosis
Postsurgical findings from
- bifrontal craniotomy for the repair of multiple dural tears, repair of comminuted frontal bone fractures, and cranialization of bilateral frontal sinuses, including using fat graft
- frontal cranioplasty including using titanium mesh
- open reduction and internal fixation of right mandibular subcondylar/ramus and right parasymphyseal fractures, of bilateral maxillae (Le Fort I fractures), of right inferior orbital rim (right Le Fort II), and left zygomaticomaxillary complex (left Le Fort II/III)
- reconstruction of bilateral orbital floors, medial orbital walls, and orbital roofs with titanium mesh
- reduction of left mandibular condylar dislocation
- application of palatal splint for closed reduction of palatal fracture
- application of dental arch bars for mandibulomaxillary fixation
Case Discussion
This patient suffered traumatic brain injury with multiple facial and skull base fractures. The term "panfacial" fracture applies where there are fractures of each third of the face. Correlating with the injuries depicted by CT and CTA, the patient did have clinical evidence of CSF rhinorrhea from the left nares, left vision loss, and left oculomotor palsy, in addition to the expected facial deformities and dental malocclusion. Extensive operative interventions were undertaken.
Regarding the classification of the facial fractures, one variation merits mention. The midfacial/pterygofacial fractures may be classified as bilateral Le Fort I, bilateral Le Fort II, and left Le Fort III fractures. However, some argue that the pterygoid plates cannot be fractured three separate times and from the standpoint of surgical management, it would also be valid to describe these as bilateral Le Fort I, bilateral NOE (naso-orbito-ethmoid), and left ZMC (zygomaticomaxillary complex) fractures 1.
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