OT Viva Prep - Panfacial Fracture ORIF

What Your CT Scans Show

• Left ZMC (Zygomaticomaxillary Complex) fracture - severely comminuted and displaced, with the malar eminence displaced inferiorly, medially, and posteriorly (Zingg Type C)
• Left orbital floor + medial wall (lamina papyracea) fracture - with blowout component; orbital volume increased
• NOE (Naso-Orbito-Ethmoid) component - comminution of nasal bones, lacrimal bones, frontal process of maxilla, likely Type III Markowitz
• Le Fort II/III pattern on the left - fracture line through pterygoid plates, infraorbital rim, lateral orbital rim (ZF suture separation)
• Bilateral midface involvement with left zygomatic arch fracture/collapse
• The right side is relatively intact; calvarium and mandible appear grossly preserved

VIVA QUESTIONS YOUR HOD WILL ASK

SECTION 1: DIAGNOSIS & IMAGING

Left panfacial smash - a combined Left ZMC fracture (Zingg Type C / comminuted), left orbital floor blowout, NOE fracture (likely Markowitz Type III), and a Le Fort II/III pattern. The right side is relatively spared. Significant comminution with loss of left malar projection and increased orbital volume.

• Type A: Isolated single buttress - A1 (zygomatic arch), A2 (lateral orbital wall/ZF suture), A3 (infraorbital rim/floor)
• Type B: Complete ZMC fracture, non-comminuted (monofragment, all 4 sutures disrupted)
• Type C: Complete ZMC fracture, comminuted (multifragment)
• This patient = Zingg Type C

• Group I: No significant displacement
• Group II: Arch fractures only
• Group III: Body fractures - unrotated
• Group IV: Body fractures - medially rotated
• Group V: Body fractures - laterally rotated
• Group VI: Complex/comminuted fractures

• Le Fort I (Horizontal/Guerin): Fracture line from pterygoid plates → lateral maxillary sinus wall → piriform aperture. Only the alveolar segment and palate are mobile ("floating palate").
• Le Fort II (Pyramidal): From pterygoid plates → lateral maxillary sinus walls → infraorbital rim → nasal bridge. The nasal-maxillary complex is mobile.
• Le Fort III (Craniofacial disjunction): From pterygoid plates → zygomatic arch base → lateral orbital walls → ZF sutures → nasal bridge. The entire midface separates from the skull base. All three pass through the pterygoid plates.

• Type I: Single central fragment, MCT (medial canthal tendon) intact
• Type II: Comminuted central fragment, MCT still attached to a large identifiable bony piece
• Type III: Comminuted with MCT avulsed from bone or attached to a tiny, unplatable fragment (requires transnasal canthopexy)
• This patient likely has Type III based on degree of comminution

Fine-cut CT (1mm slices) with axial, coronal, and sagittal MPR views plus 3D reconstruction. Axial best for zygomatic arch and anterior-posterior displacement; coronal best for orbital floor, medial wall, and NOE; sagittal for orbital volume assessment. Plain X-rays (Waters', OPG, PA skull) are insufficient for complex fractures and pre-operative planning.

Posterior displacement of the globe into an enlarged bony orbit. In this patient, the collapsed orbital floor and medial wall increase orbital volume - orbital fat and extraocular muscles herniate downward into the maxillary/ethmoid sinus. Each 1 mL increase in orbital volume = approximately 0.8 mm of enophthalmos.

SECTION 2: CLINICAL FEATURES

• Flattening of the malar eminence (loss of cheek projection)
• Periorbital ecchymosis and subconjunctival hemorrhage (no posterior limit = posterior extension toward optic nerve)
• Step deformity at infraorbital rim, ZF suture, and zygomatic arch
• Infraorbital nerve paresthesia (cheek, upper lip, side of nose, upper teeth)
• Restricted mouth opening (zygomatic arch impinging on coronoid process)
• Diplopia (inferior oblique/rectus entrapment or edema)
• Enophthalmos/hypoglobus (orbital floor fracture)
• Emphysema on blowing nose (connection to maxillary sinus)

It indicates blood tracking from the orbital contents forward under the conjunctiva. When there is no visible posterior limit to the hemorrhage, it suggests a fracture of the orbital walls - blood is coming from behind. A posterior limit suggests the hemorrhage is confined anteriorly (likely direct trauma, not orbital fracture).

Bruising over the mastoid process (post-auricular ecchymosis) indicating a base of skull fracture (petrous temporal bone fracture). It is important to check for it in high-energy facial trauma. Not directly from a ZMC fracture but relevant in panfacial injuries to rule out intracranial injury.

The infraorbital nerve (V2, maxillary division of trigeminal) runs through the infraorbital canal and exits at the infraorbital foramen. Supplies: skin of cheek, lower eyelid, lateral nose, upper lip, and the upper anterior teeth. Test with a wisp of cotton to compare both sides. Always document pre-operatively.

SECTION 3: AIRWAY & ANESTHESIA

Midface fractures can make mask ventilation difficult and laryngoscopy challenging. Options are:

• Nasotracheal intubation - preferred in mandible + maxilla fractures to allow intraoperative occlusal assessment; but CONTRAINDICATED if cribriform plate injury or NOE/Le Fort III fractures (risk of intracranial tube passage)
• Oral endotracheal intubation with tube routed through a retromolar gap or dental extraction gap
• Submental intubation - incision in the floor of mouth, tube brought through submentally, preserves nasal access and occlusion assessment
• Tracheostomy - for severe airway compromise, extensive panfacial injuries
• In this patient with NOE involvement - nasotracheal route is relatively contraindicated

A technique where the flexometallic endotracheal tube is inserted orally then the connector end is passed through a 1.5 cm incision in the submental skin, through the floor of mouth, into the submental space. This gives:

• Clear nasal field (NOE repair)
• Clear oral field (dental occlusion check)
• Avoids tracheostomy
• Used in panfacial fractures, NOE + mandible + maxilla combined fractures

Stridor, hoarse voice, subcutaneous emphysema, tracheal deviation, paradoxical breathing, oxygen desaturation, drooling, inability to swallow, blood/secretions in oropharynx, decreased GCS. Any suspicion = early intubation before edema worsens.

SECTION 4: SURGICAL APPROACH & TECHNIQUE

A 2 cm incision is made within the hairline in the temporal region. Gillies elevator is passed deep to the temporalis fascia (superficial layer) and superficial to the temporal fascia's deep layer, then under the zygomatic arch. Firm upward and outward levering motion reduces the depressed arch or zygomatic body. Used for isolated, non-comminuted fractures. Not suitable for comminuted fractures like this patient's.

• Bottom-up, inside-out: Mandible → maxilla → midface → upper face. Starts with the stable base (mandible), restores lower face height, then builds upward.
• Top-down, outside-in: Skull base/frontal → zygomatic arches → midface → mandible. Starts with intact upper structures as reference.
• Most modern protocols favor a combined approach - restore the stable bony frame (ZA, frontal bar) first, then sequence internally. The key principle is to restore facial width, height, and projection.

The craniofacial buttresses (Manson's concept):

• Vertical buttresses: Nasomaxillary, zygomaticomaxillary, pterygomaxillary
• Horizontal buttresses: Frontal bar (superior), infraorbital rim (middle), maxillary alveolus (inferior)

Fix the strongest, most stable buttress first. In this case: restore the ZF suture (stable top), then ZM buttress, then infraorbital rim, then orbital floor.

• Titanium miniplates: 1.5 mm (midface) for ZM buttress, infraorbital rim
• Titanium microplates: 1.0 mm or 0.8 mm for orbital rim
• Titanium mesh: For orbital floor/wall reconstruction (to restore orbital volume and prevent enophthalmos)
• Screws: Self-tapping, monocortical screws (4-6 mm) for midface
• Alloplastic materials (Medpor, titanium mesh with PDS foil) for orbital floor if defect > 2 cm²

In panfacial injuries, the key fracture is the one fracture that, once reduced and fixed, provides the reference point for all other reductions. In ZMC fractures, the ZF suture (zygomaticofrontal suture) is the most accessible and provides rotational stability - it is typically plated first as the key point.

SECTION 5: ORBITAL FLOOR / BLOWOUT

• Hydraulic theory (Converse & Smith): Sudden increase in intraorbital pressure from direct globe trauma transmits force to the weakest orbital wall (floor/medial wall), causing it to buckle outward.
• Buckling theory (Fujino): Direct force to the orbital rim is transmitted along the bone to the orbital floor, causing the floor to buckle inferiorly.
• Both mechanisms likely contribute.

• Diplopia that does not resolve within 2 weeks (muscle entrapment)
• Enophthalmos > 2 mm (or predicted >2 mm based on orbital volume)
• Orbital floor defect > 50% of floor area (or > 2 cm²)
• White-eyed blowout in children (trapdoor fracture - urgent, within 24-48 hrs)
• Significant hypoglobus

A trapdoor orbital floor fracture predominantly seen in children. The elastic bone springs back trapping the inferior rectus/fat without significant bruising or external signs ("white eye"). A surgical emergency - the ischemic muscle must be released within 24-48 hours to prevent permanent motility defect. The "trapdoor" effect is due to the greenstick nature of pediatric bone.

• Autogenous: Calvarial bone graft (split thickness), costal cartilage, iliac crest - gold standard for large defects
• Alloplastic: Titanium mesh (most common), porous polyethylene (Medpor), nylon foil, resorbable PDS plates
• Small defects (< 1 cm²) may not require grafting

SECTION 6: NOE FRACTURES

• Telecanthus - increased intercanthal distance (normal = 30-34 mm, or half of interpupillary distance)
• Traumatic epiphora - lacrimal system disruption
• Flattened nasal bridge / saddle nose deformity
• Subconjunctival hemorrhage
• Periorbital ecchymosis ("raccoon eyes" bilaterally)
• Nasal airway obstruction
• CSF rhinorrhea (if cribriform disrupted)

Bowstring test: Grasp the medial canthal region with two fingers and pull laterally. Firm resistance indicates intact MCT. Loss of resistance or ability to displace the medial canthus > 5 mm suggests MCT avulsion or detachment from bone (Type II/III NOE fracture).

Transnasal canthopexy: Pass a stainless steel wire or permanent suture through a drill hole in the nasal bone/lacrimal crest, route it transnasally through the contralateral side, and tie with overcorrection of the canthal position. The goal is to resupport the MCT at or slightly posterior and superior to its normal anatomic position (because the nasal bones may be posterior to their normal position). Overcorrection is intentional.

SECTION 7: COMPLICATIONS

• Infraorbital nerve injury
• Infraorbital artery hemorrhage
• Damage to the globe/extraocular muscles
• CSF leak (if NOE component exists)
• Incomplete reduction

• Infection / wound dehiscence
• Hematoma
• Edema
• Sinus congestion / sinusitis

• Enophthalmos / hypoglobus (untreated or undertreated orbital volume increase)
• Persistent diplopia
• Infraorbital nerve hypoesthesia (most common permanent complication)
• Ectropion (from subciliary incision)
• Malunion / hardware exposure / plate palpability
• Epiphora (lacrimal system injury in NOE component)
• Telecanthus relapse

Outward rotation/sagging of the lower eyelid. Prevented by: using a stepped (skin-muscle flap) or transconjunctival approach instead of subciliary; reattaching the orbicularis oculi to the periosteum; avoiding aggressive retraction; closing in layers; using a lateral canthotomy and canthopexy if extensive orbital dissection was done.

SECTION 8: TIMING

"The 2-week window":

• Early (within 7-10 days): before edema, hematoma organization, early fibrous union
• If delayed > 2-3 weeks: bone begins to fibrose, making reduction harder
• NOE/orbital floor: Should be done within 1-2 weeks (before scar contracture causes cicatricial enophthalmos)
• Panfacial fractures: Ideally 5-10 days post-injury, when swelling begins to subside (allowing better reduction) but before fibrous union
• Life-threatening injuries take priority - stabilize first (ABC), face can wait 7-10 days if stable

SECTION 9: ANATOMY QUESTIONS

1. Zygomaticofrontal (ZF) suture - lateral orbital rim
2. Zygomaticomaxillary (ZM) suture - infraorbital rim + anterior maxilla
3. Zygomaticotemporal (ZT) suture - zygomatic arch
4. Zygomaticosphenoidal - posterior lateral orbital wall

• Vertical (pillars): Nasomaxillary, zygomaticomaxillary (strongest), pterygomaxillary
• Horizontal (beams): Supraorbital bar, infraorbital rim, maxillary alveolus
• These transmit masticatory forces to the skull base. ORIF aims to restore these buttresses.

The infraorbital foramen lies 4-7 mm below the infraorbital rim, in the midpupillary line. Plates must be placed to avoid the foramen. Screws placed superior to the foramen risk nerve injury.

• Roof: Frontal bone (orbital plate) + lesser wing of sphenoid
• Floor: Maxilla (orbital surface), palatine bone, zygomatic bone - thinnest wall, most commonly fractured
• Medial wall: Maxilla, lacrimal, ethmoid (lamina papyracea - thinnest), sphenoid - second most commonly fractured
• Lateral wall: Zygomatic bone + greater wing of sphenoid - strongest wall

SECTION 10: QUICK-FIRE BONUS QUESTIONS

Entrapment of the inferior rectus or inferior oblique muscle (or peri-muscular fat) in the fracture - restricts upgaze and causes diplopia looking up. Forced duction test positive (inability to elevate the globe passively with forceps on the conjunctiva).

Elevated appearance of the orbit on the fractured side on a Waters' view (occipito-mental view), due to ZMC fracture causing the orbital outline to appear raised/asymmetric.

A herniated mass of orbital fat (or inferior rectus muscle) hanging through an orbital floor defect into the maxillary sinus, shaped like a teardrop. Indicates a significant orbital floor fracture requiring repair.

The depressed zygomatic arch fragment impinges on the temporal surface of the coronoid process of the mandible, physically blocking mouth opening. This is reduced by lateral traction to free the arch off the coronoid.

IMF establishes the correct dental occlusion as the intraoperative reference point. Arch bars (Erich arch bars) are applied to upper and lower teeth, and the jaws are wired into occlusion. For this patient (primarily midface, no mandible fracture), IMF may be used to confirm and reference the maxillary position during plating.

Standard: IV Cefazolin 1-2g at induction (or Clindamycin if penicillin-allergic). For sinus-communicating fractures (all Le Fort/ZMC fractures communicate with maxillary sinus), extend to 5-7 days post-op with oral Amoxicillin-Clavulanate. Some units add a nasal decongestant to facilitate sinus drainage.

Summary for Rapid Recall Before You Scrub In