白袍恐懼症

Facial fracture

1.      nasalorbitalethmoid fracture(NOE fracture)

Blunt force directly over the nasal pyramid.

Commonly bilateral, but 1/3 unilateral.

The nasoorbitoethmoid (NOE) complex is the confluence of the frontal sinus, ethmoid sinuses, anterior cranial fossa, orbits, frontal bone, and nasal bones.

Long-term sequelae of NOE fractures include blindness, telecanthus, enophthalmos, midface retrusion, cerebral spinal fluid (CSF) fistula, anosmia, epiphora, sinusitis, and nasal deformity.

medial canthal tendon: 分為anterior, posterior,以及superior三個部份，包住lacrimal sac

Orbicularis oculi:分為pretarsal, preseptal,以及orbital portion三個部份

都是源自於medial canthal tendon，中止於lateral canthal tendon(除了orbital portion)

Classification

Type 1: single segment central fracture with medial canthal tendon attached.

Type 2: comminuted fracture with medial canthal tendon attached.

Type 3: comminuted fracture with avulsed medial canthal tendon

PE:

-Loss of dorsal-nasal prominence

-Glabellar, periorbital, nasal ecchymosis

-Telecanthus>35mm(眼距過寬，normal 30~32mm)

-Bowstring test: lateral traction of lower eyelid will result in telecanthus if ligament is disrupted.

-Rhinorrhea: avoid CSF leakage

-Olfactory disturbance

2.      maxillary fracture(LeFort Fracture)

Le Fort I Fracture = Horizontal Fracture

Clinical:

Facial edema

Malocclusion of the teeth

Motion of the maxilla while the nasal bridge remains stable

Le Fort II Fracture = Pyramidal Fracture

Clinical:

Marked facial edema

Nasal flattening

Traumatic telecanthus

Epistaxis or CSF rhinorrhea

Movement of the upper jaw and the nose.

Le Fort III Fractures = Craniofacial Separation 

Clinical:

Dish faced deformity

Epistaxis and CSF rhinorrhea

Motion of the maxilla, nasal bones and zygoma

Severe airway obstruction 

3.      mandibular fracture

4.      Orbital Fractures

(1). Composed of 7 bones:

Zygoma, sphenoid, ethmoid, frontal, palatine, maxilla, lacrimal

(2). Weakest structure: medial wall

(3). Superior orbital fissure: CN3, 4, 5-1, 6

(4). Inferior orbital fissure: CN5-2, sphenopalatine ganglion, inferior ophthalmic vein

Superior orbital fissure(SOF) syndrome: fractures of the SOF result in

-fixed dilated pupil (CN 3)

-upper lid ptosis (CN 3)

-loss of corneal reflex (CN 5-1)

-ophthalmoplegia (CN 4,5-1)

Orbital apex syndrome: SOF syndrome+ impairment of optic nerve

Type of orbital fractures

1.      orbital floor (blow out): fractures most commonly occur at medial wall and floor of the orbit along the infraorbital groove. A fracture defect may entrap periorbital fat and possibly the inferior rectus muscle. 症狀: 1.眼週邊瘀血、腫  2.enophthalmos (若眼球仍oedema反而是proptosis)  3. infraorbital nerve anaesthesia (下眼瞼、臉頰、鼻側、上唇、上牙齦) 4.複視: 多為 vertical diplopia  5.orbital emphysema (嚴重時由sinus來)

2.      orbital roof (blow in): rare, due to protection by the supraorbital rimand frontal bone. If injury to the supraorbital artery can result in a retrobulbar hematoma.

Surgical indications

-early enophthalmos>2mm

-symptomatic diplopia>2 weeks

-displaced fracture with floor defect>1 cm2

-hypoglobus: low vertical lying globe

-positive forced duction test

-oculocardiac response: nausea, vomiting, bradycardia, and syncope