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Intraoperative Questions Your HOD is Likely to Ask - ORIF Facial Fractures

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1. Fracture Identification & Classification

• "What fractures do you see on this CT? Describe them systematically."
• "Is this a ZMC fracture, NOE fracture, or a panfacial fracture - how do you classify it?"
• "What are the four articulations of the zygoma? Which ones are disrupted here?"
• "What is the Zingg/Knight-North classification of zygomatic fractures?"
• "Is there an orbital floor blow-out? How do you differentiate a pure vs impure blow-out fracture?"
• "What is the 'trap-door' fracture and why is it a surgical emergency?"
• "Does this CT suggest Le Fort involvement? How would you differentiate Le Fort I, II, and III?"
• "Is there NOE involvement? What is the Markowitz classification of NOE fractures?"

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2. Pre-operative Assessment

• "What is your pre-op checklist before taking this patient to OR?"
• "Has ophthalmology evaluated this patient? Why is that mandatory before orbital ORIF?"
• "What signs would make you suspect a retrobulbar haematoma? What is your emergency management?"
• "What was the pre-operative visual acuity and ocular motility assessment?"
• "Is there diplopia? What does it suggest - blow-out with entrapment vs nerve injury?"
• "What is the enophthalmos/exophthalmos on examination and CT measurements?"
• "Did you check for CSF leak? What is the Battle's sign / raccoon eyes significance here?"
• "Have you assessed pre-operative occlusion (dental bite)? Is there malocclusion?"

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3. Timing of Surgery

• "Why do we wait 7-10 days before operating on facial fractures in most cases?"
• "What are the exceptions - when do you operate immediately on facial fractures?"
• "What is the 'rule of 7-10 days' and why does edema matter for surgical planning?"

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4. Surgical Approach & Incisions

• "What approach will you use to access the right orbital rim / floor?"
  • Subtarsal / infra-orbital / transconjunctival - difference?
• "What is the coronal approach? When is it indicated for facial fractures?"
• "How do you approach the frontozygomatic suture? Why does it need fixation first?"
• "What is the gingivobuccal sulcus (Caldwell-Luc) incision? What does it expose?"
• "What is the sequencing of fixation in a complex facial fracture - where do you start?"
  • "Top-down vs bottom-up - what is your preferred approach and why?"
• "What is the role of a lateral eyebrow/upper lid crease incision in orbital work?"
• "How do you protect the infraorbital nerve during this approach?"

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5. Fixation Principles

• "What size plates and screws do you use for the orbital rim vs zygomatic arch vs mandible?"
  • Microplates (0.8-1.0 mm), mini-plates (1.5-2.0 mm), reconstruction plates (2.4 mm) - when?
• "What material are these plates? Titanium vs bioresorbable - pros and cons?"
• "What is the minimum number of screws required on each side of a fracture?"
• "What is rigid vs semi-rigid fixation? Which does the face require?"
• "What is MMF (maxillomandibular fixation)? When do you apply it and when do you remove it?"
• "What are Ivy loops / Erich arch bars / Ernst ligatures? How are they applied?"
• "What are Rowe disimpaction forceps? When are they used?"

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6. Orbital Floor / Blow-out Specific

• "What is the critical orbital volume - when must you reconstruct the floor?"
• "What materials do you use for orbital floor reconstruction?"
  • Titanium mesh, PDS foil, autologous bone, naso-septal cartilage
• "What is the 'trapdoor' sign on CT? How does it affect your urgency?"
• "How do you check the adequacy of orbital floor repair intraoperatively?"
• "What is the forced duction test? How and when do you perform it?"
• "How do you prevent iatrogenic injury to the inferior rectus and inferior oblique?"

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7. ZMC (Zygomatic Complex) Specific

• "How do you reduce a displaced ZMC intraoperatively? What instrument do you use?"
  • Gillies temporal approach, Carroll-Girard screw, Keen's approach
• "At how many points do you fix a ZMC fracture - 2-point vs 3-point vs 4-point fixation?"
• "What is the Gillies approach? Describe the steps."
• "How do you confirm adequate reduction of the ZMC intraoperatively?"

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8. NOE Fractures

• "What is telecanthus? How do you measure medial canthal tendon displacement?"
• "What is transnasal canthopexy? How is it performed?"
• "What is the difference between type I, II, and III NOE fracture in Markowitz classification?"
• "What bone grafting might be needed for comminuted NOE fractures?"

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9. Intraoperative Complications

• "What are the dangers of this surgery - list intraoperative complications?"
  • Retrobulbar haematoma, CSF leak, ectropion, lacrimal injury, infraorbital nerve injury, enophthalmos
• "Patient's pupil dilates intraoperatively - what is your management?"
• "You notice CSF coming from the ethmoid region - what now?"
• "How do you manage intraoperative bleeding from the pterygoid plexus?"

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10. Post-operative Concerns

• "What is your post-op ophthalmology monitoring protocol?"
• "How often do you check visual acuity post-op and for how long?"
• "What is ectropion and how do you prevent it during approach and closure?"
• "When do you start physiotherapy / jaw mobilisation?"
• "What are the signs of plate infection - how do you manage?"
• "When would you remove hardware - what are your indications?"

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11. Anatomy Spot Questions

• "Name the four suture lines of the zygoma."
• "What passes through the infraorbital foramen? At what distance from the infraorbital rim?"
• "What is the Whitnall tubercle? What attaches here?"
• "What are the contents of the orbit? Name the layers of the orbital walls."
• "Which is the thinnest wall of the orbit?" (medial wall / lamina papyracea)
• "What nerve supplies sensation to the cheek? How is it at risk here?"

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Quick Recall Anchors

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ORIF Facial Fractures - Complete Q&A

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SECTION 1: FRACTURE IDENTIFICATION & CLASSIFICATION

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• Right orbit - comminuted, involving the orbital floor and medial wall
• Right zygomaticomaxillary complex (ZMC) - disrupted at all four suture lines
• Naso-orbito-ethmoid (NOE) region - with comminution of the nasal root area
• Nasal bones - fractured and displaced
• Possibly Le Fort II level involvement given the orbital and maxillary extent

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1. Frontozygomatic suture (zygomaticofrontal - FZ suture)
2. Zygomaticomaxillary suture (at the infraorbital rim and anterior maxillary buttress)
3. Zygomaticotemporal suture (at the zygomatic arch)
4. Zygomaticosphenoid suture (at the lateral orbital wall / greater wing of sphenoid)

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• Type A - Isolated fracture of one of the three processes (A1 = arch, A2 = infraorbital rim, A3 = lateral orbital rim)
• Type B - Classic tetrapod/tripod fracture - all four suture lines fractured but one fragment (monofragment)
• Type C - Comminuted fracture of the zygomatic body (multifragment)

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• Group I - No significant displacement
• Group II - Arch fracture only
• Group III - Unrotated body fractures
• Group IV - Medially rotated body fractures
• Group V - Laterally rotated body fractures
• Group VI - Complex/comminuted fractures

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• Blow-out fracture - sudden rise in intraorbital pressure (e.g., blunt trauma from a ball/fist) causes the thin orbital walls to fracture outward while the orbital rim remains intact.
• Pure blow-out - only the orbital wall fractures; the rim is intact
• Impure blow-out - orbital wall fracture + rim fracture (e.g., in ZMC fracture, the floor fractures along with the rim)
• Most common wall: orbital floor (next to the maxillary sinus), followed by medial wall (lamina papyracea)

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• Restricted eye movement / diplopia
• Oculocardiac reflex (bradycardia, nausea, vomiting) - especially in children
• It is a surgical emergency because prolonged ischemia causes permanent muscle necrosis. Ideal repair: within 24-48 hours.

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• Type I - Single non-comminuted fragment; medial canthal tendon (MCT) still attached to a large enough bone fragment - treated by stabilizing the fragment with rigid fixation
• Type II - Comminuted bone but MCT is still attached to a small bone fragment - treated by transnasal/transcanthal fixation with wire or permanent suture (the small fragment cannot take a plate)
• Type III - Complete disruption of MCT from bone - treated by direct transnasal canthopexy (wire passed across the nose to reattach the tendon)

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SECTION 2: PRE-OPERATIVE ASSESSMENT

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• Ruptured globe
• Retrobulbar haematoma
• Optic nerve injury
• Retinal detachment
• Vitreous haemorrhage A pre-op ophthalmology assessment documents baseline visual acuity, intraocular pressure, and ocular motility. If vision is already lost pre-op, it cannot be blamed on surgery. If there is a ruptured globe, orbital manipulation is contraindicated until repaired.

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• Sudden proptosis post-injury or post-op
• Rock-hard orbit on palpation
• Rapidly decreasing visual acuity
• Afferent pupillary defect (APD) / RAPD
• Increasing IOP (>40 mmHg)
• Pain on eye movement

1. Immediate lateral canthotomy and cantholysis (bedside procedure)
2. IV Mannitol 1-2 g/kg to reduce IOP
3. IV Dexamethasone
4. Urgent ophthalmology review
5. Return to OR for formal orbital decompression if needed

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• Caused by either muscle entrapment (inferior rectus trapped in fracture) or by orbital fat herniation displacing the eyeball
• Persistent diplopia >7 days is a surgical indication
• On forced duction test - if positive (restricted passive movement) = entrapment
• If diplopia is from muscle contusion/oedema alone, it may resolve spontaneously

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• Enophthalmos >2 mm
• Orbital floor defect >2 cm² or involving >1/3 to 1/2 of the orbital floor The most common error in orbital floor reconstruction is failure to repair the posterior orbital floor.

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• Purpose: to differentiate entrapment (positive test) from paresis/contusion (negative test)
• Technique: Under topical or local anaesthesia, the conjunctiva near the limbus is grasped with toothed forceps and the globe is manually rotated in the direction of restricted movement
• Positive test = resistance to passive movement = entrapment of muscle or tissue
• Performed both before and after surgery to confirm release of entrapped tissue

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SECTION 3: TIMING OF SURGERY

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• Acute facial oedema obscures landmarks and makes accurate reduction difficult
• Swollen soft tissues are fragile and dehisce easily
• Time allows patient stabilisation and optimisation (airway, ICP, other injuries)
• Haematoma organises and partially liquefies, making tissue planes easier to dissect
• Standard recommendation: 7-14 days for most facial fractures

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1. Trapdoor fracture with oculocardiac reflex (children) - within 24-48 hours
2. Retrobulbar haematoma with visual loss
3. Fractures involving the cranium / depressed fractures threatening the brain
4. Open fractures with severe contamination
5. Fractures compromising the airway
6. Injuries involving the lacrimal ducts (duct must be stented early)
7. Severe haemorrhage from facial fractures requiring angioembolisation

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SECTION 4: SURGICAL APPROACH & INCISIONS

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1. Subciliary (subtarsal) approach - incision 2-3 mm below the lower lid lash line through skin, orbicularis; stepped dissection to the infraorbital rim. Best cosmesis but risk of ectropion.
2. Transconjunctival approach - incision through conjunctiva, either preseptal or postseptal. No external scar, lower ectropion risk. May need lateral canthotomy for access.
3. Infraorbital (mid-lid) approach - incision in a skin crease 5-8 mm below lid margin. Easier access but visible scar.

• Most favoured: transconjunctival (lowest ectropion rate)
• Transconjunctival can be preseptal (between orbicularis and septum) or postseptal (directly through the septum and fat)

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• Bicoronal incision from ear to ear across the top of the head (within hairline)
• Allows access to: frontal bone, frontozygomatic suture, zygomatic arches, NOE region, nasofrontal junction, orbital rims
• Used for: Le Fort III, complex panfacial fractures, NOE fractures, frontal sinus fractures
• Risk: injury to branches of facial nerve (temporal branch), alopecia at scar, haematoma

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• Incision along the upper gum at the mucogingival junction (buccal sulcus)
• Provides access to: anterior maxillary buttress, zygomaticomaxillary buttress, inferior orbital floor (from below), infraorbital nerve
• Used for: Le Fort I, ZMC fixation at the ZM buttress, maxillary osteotomies
• Risk: infraorbital nerve injury, damage to tooth roots, oro-antral fistula

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1. Re-establish occlusion first (MMF / arch bars)
2. Fix the frontozygomatic suture (highest stable point)
3. Fix the zygomatic arch
4. Fix the infraorbital rim
5. Fix the zygomaticomaxillary buttress
6. Repair the orbital floor/walls
7. Fix the NOE region / nasofrontal
8. Final check at Le Fort I level

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• The infraorbital nerve exits the infraorbital foramen approximately 6-8 mm below the infraorbital rim (midpoint)
• During gingivobuccal sulcus approach, stay subperiosteal and identify the nerve before placing retractors
• Avoid placing screws in the nerve's path
• Use microplates at the infraorbital rim to avoid bulk that may compress the nerve under the skin
• Post-op paraesthesia in the cheek/upper lip is the most common complication of infraorbital nerve injury

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SECTION 5: FIXATION PRINCIPLES

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1. Erich arch bars - malleable metal bars wired to upper and lower teeth, then jaws wired together; most reliable
2. Ivy loops - simple wire loops around individual teeth used to wire jaws together; quick, less rigid
3. Ernst ligatures - similar wire loop technique
4. IMF screws - titanium screws placed directly into maxilla and mandible; faster but not suitable for all cases

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• Specially designed forceps with curved blades: one blade placed intraorally over the hard palate, the other externally over the nasal bridge
• Used to disimpact and reduce impacted Le Fort fractures (especially Le Fort II/III where the midface is driven posteriorly and superiorly)
• The forceps provide controlled downward and forward traction to reduce the impaction before applying fixation

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SECTION 6: ORBITAL FLOOR RECONSTRUCTION

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1. Titanium mesh (0.4-0.6 mm) - most commonly used; rigid, visible on post-op CT, allows confirmation of placement
2. PDS (Polydioxanone) foil - resorbable, used for smaller defects
3. Neopore / porous polyethylene (Medpor) - allows tissue ingrowth; strong, permanent
4. Autologous bone graft - rib, calvarium, iliac crest; gold standard for large defects; avoids implant infection but donor site morbidity
5. Nasal septal cartilage - for smaller defects
6. Gelfilm / fascial grafts - for small entrapment cracks; not structural

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1. Forced duction test - repeat after repair; should be negative (free movement)
2. Intraoperative CT - for radio-opaque implants (titanium mesh), confirms position
3. Visual inspection - check that the globe position appears symmetric
4. Hertel exophthalmometry - compare both eyes
5. "Globe on implant" test - confirm the implant spans the entire defect including the posterior ledge

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SECTION 7: ZMC FRACTURE MANAGEMENT

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1. Gillies temporal approach (most classical) - incision in the temporal hairline, a flat elevator (Bristow elevator) is passed deep to the temporalis fascia and under the zygomatic arch, and upward leverage is applied to reduce the depressed zygoma
2. Carroll-Girard screw - a threaded screw inserted transcutaneously into the zygomatic body; gives a 3D grip to rotate and reduce the fragment in all planes
3. Keen's approach - incision in the gingivobuccal sulcus, an elevator placed behind the zygomatic buttress to lever the zygoma back out
4. Percutaneous hook - for isolated arch fractures

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• 2-point fixation: FZ suture + ZM buttress (for minimally displaced)
• 3-point fixation (standard): FZ suture + infraorbital rim + ZM buttress
• 4-point fixation: as above + zygomatic arch (for severely displaced/comminuted)

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1. Alignment at all four fixation points - the fracture lines should be flush
2. Frontozygomatic suture alignment (primary reference point)
3. Infraorbital rim step-off - should be absent
4. Symmetry of malar eminence - compare both sides
5. Lateral canthal height - should be symmetric with the opposite side
6. Palpation of the zygomatic arch - should be convex and symmetric

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SECTION 8: NOE FRACTURE MANAGEMENT

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• Telecanthus = increased intercanthal distance (medial canthal tendons displaced laterally)
• Normal intercanthal distance: 30-35 mm (3.0-3.5 cm); roughly equal to the width of one eye (interpupillary distance = 2x intercanthal distance)
• Measured clinically with a ruler from medial canthus to medial canthus
• On CT: measure the distance between the MCT insertion points
• Bowstring test: pushing a finger medially on the medial canthal tendon - if it gives way easily, the tendon is disrupted

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• Used for Type II and III NOE fractures where the MCT cannot be rigidly fixed
• A transnasal wire (typically 26-28 gauge stainless steel wire or PDS suture) is passed:
  1. Through a drill hole made in the nasal bone / medial orbital wall on the opposite (healthy) side - posterior, medial, and superior to where the tendon should attach
  2. The wire is passed across the nasal bridge using a wire passer
  3. It is attached to the MCT (or the bone fragment with the tendon in Type II)
  4. The tendon is pulled posteriorly, medially, and superiorly (the three critical directions)
  5. Wire is tied over a bolster or button on the contralateral side
• Critical: the tendon must be repositioned posterior, medial, and superior - NOT anterior/lateral/inferior (which is the natural pull direction)

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SECTION 9: INTRAOPERATIVE COMPLICATIONS

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1. Retrobulbar haematoma - from orbital vessel injury; emergency; lateral canthotomy + cantholysis
2. Globe injury (penetrating - very rare) - call ophthalmology immediately
3. Infraorbital nerve injury - paraesthesia in cheek/upper lip; avoid with careful technique
4. Facial nerve branch injury - especially temporal branch in coronal approach; frontal branch in FZ exposure
5. CSF leak - if NOE or frontal sinus fracture involves cribriform plate or dural injury
6. Bleeding from pterygoid plexus - pack, pressure; difficult to ligate directly
7. Ectropion - from lower lid approaches; avoid by careful closure, avoid tension
8. Lacrimal drainage injury - identify and stent the nasolacrimal duct/canaliculus if at risk
9. Air embolism - rare, from sinus involvement
10. Muscle entrapment - failure to release inferior rectus from floor; check with forced duction

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• STOP surgery immediately
• A dilating pupil (blown pupil = mydriasis with loss of light reflex) = cranial nerve III compression OR retrobulbar haematoma OR direct optic nerve injury
• Check both eyes; is it an APD (afferent defect) or efferent (CN III)?
• If retrobulbar haematoma suspected: immediate lateral canthotomy + cantholysis; release orbital pressure
• Neurosurgical emergency if CN III compression from intracranial cause
• Get urgent ophthalmology review
• Consider intraoperative CT if available

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• Identify the source - cribriform plate or fovea ethmoidalis is most likely
• Pack with a fat graft or fascia lata (free graft) over the defect
• Can use dural sealant (DuraSeal/fibrin glue)
• Do not irrigate forcefully
• Head of bed elevation 30 degrees post-op
• Avoid nose blowing, straining, sneezing
• Most traumatic CSF leaks resolve within 7-10 days conservatively
• If persistent >10 days: neurosurgical review for formal dural repair
• Give prophylactic antibiotics (controversial but commonly used for compound fractures with CSF leak)

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SECTION 10: POST-OPERATIVE CARE

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• Visual acuity check every 1 hour for first 4 hours post-op (peak time for retrobulbar haematoma)
• Then every 4 hours for 24 hours
• Pupillary response checked alongside
• If visual acuity drops or pupil changes: immediate action (lateral canthotomy)
• Formal ophthalmology review at 24-48 hours post-op
• Follow-up at 1-2 weeks for diplopia assessment
• Hertel exophthalmometry at 1 month

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• Ectropion = lower eyelid everts outward (scleral show)
• Caused by: scar contracture pulling the lid down, over-zealous skin excision, failure to re-suspend the lower lid
• Prevention:
  1. Use transconjunctival approach (lowest ectropion rate)
  2. If subciliary used: meticulous layered closure, no skin tension
  3. Temporary tarsorrhaphy suture (may be placed at end of procedure)
  4. Lateral canthopexy at closure to re-suspend the lid
  5. Avoid placing thick/bulky implants that push the lid forward

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1. Plate infection / osteomyelitis
2. Palpable/painful hardware
3. Plate fracture (rare)
4. Growing child (always remove to prevent restriction of facial growth)
5. Exposure through overlying soft tissue
6. Interference with dental implants

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SECTION 11: ANATOMY VIVA

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1. Frontozygomatic (FZ) suture
2. Zygomaticomaxillary suture
3. Zygomaticotemporal suture
4. Zygomaticosphenoid suture

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• Infraorbital nerve (branch of V2 / maxillary division of trigeminal)
• Infraorbital artery and vein

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• A small bony prominence on the inner aspect of the zygomatic bone, just inside the lateral orbital rim (approximately 11 mm below the frontozygomatic suture)
• Attachments:
  1. Lateral canthal tendon (lateral palpebral ligament)
  2. Lockwood's suspensory ligament of the eyeball
  3. Lateral check ligament of the lateral rectus
  4. Lacrimal fascia
  5. Aponeurosis of the levator palpebrae superioris (lateral horn)
• Important: in ZMC fractures, Whitnall tubercle may be avulsed, causing lateral canthal displacement

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• Medial wall - formed by the lamina papyracea of the ethmoid bone (literally "paper-like plate") - thinnest at 0.2-0.4 mm
• Also thin: orbital floor (especially the posteromedial part over the maxillary sinus)
• Thickest wall: lateral wall (greater wing of sphenoid + zygomatic bone)

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QUICK REFERENCE SUMMARY TABLE

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