Facial Fractures
- The face is a stack of bony struts and arches; trauma reads as a "follow the crack" puzzle, and CT with bone windows is how you solve it.
- Some patterns matter more than isolated cracks: orbital floor blowouts, zygomaticomaxillary complex (ZMC) fractures, and the Le Fort fractures that detach the midface from the skull base.
- The single unifying rule of Le Fort: every Le Fort fracture crosses the pterygoid plates. No pterygoid involvement, not a Le Fort.
- Don't just name the bone — look for the company a fracture keeps: trapped muscle, the eye, the airway, and bleeding.
Think of the facial skeleton as a set of crumple zones welded onto the front of a helmet. Evolution built it to take a hit — to fold, buckle, and absorb energy so the brain behind it survives. That's great for the patient and slightly annoying for you, because "designed to break in predictable ways" means there's a whole vocabulary of named patterns you're expected to recognize on sight. The good news: once you see the architecture, the fractures stop being random and start being almost logical.
First, the scaffolding
The midface is held together by a lattice of vertical and horizontal buttresses — thicker columns of bone that carry chewing forces up into the skull, like the load-bearing studs in a wall. Between them are thin plates that exist mostly to hold shape, the bony equivalent of drywall. Trauma tends to fold the thin stuff and snap along or across the buttresses, which is exactly why the patterns repeat.
The workhorse study is a maxillofacial CT read on bone windows, with coronal and sagittal reformats. If windows feel hazy, it's worth a two-minute detour through windowing and reconstruction planes — on facial bones the wrong window can hide a hairline fracture completely.
The orbital floor blowout
Here's the classic. A fist or a baseball strikes the eye, pressure spikes inside the orbit, and the weakest wall gives way — usually the thin orbital floor, sometimes the medial wall. The rim often survives intact, which is the whole point of the word blowout: the contents blow out through a hole, like stepping on a juice box and watching it squirt from the side.
On coronal CT you're hunting for orbital fat (and sometimes the inferior rectus muscle) drooping down into the maxillary sinus through the floor defect — the so-called teardrop sign, hanging from the sinus roof.
The real emergency in a blowout isn't the bone — it's an entrapped muscle. If the inferior rectus gets pinched in the fracture, the eye can't look up, and in kids the bone can snap shut like a trapdoor with the muscle inside (the "white-eyed blowout," where the CT looks deceptively unimpressive). That's a surgical clock, not a routine follow-up.
For the deeper dive on the eye itself, see orbital trauma.
The ZMC ("tripod") fracture
The cheekbone — the zygoma — is a freestanding arch bolted to the rest of the face at a few points. Hit it hard enough and those attachments give as a unit: the zygomaticomaxillary complex, still affectionately called a "tripod" fracture even though it really involves four articulations. Look for breaks at the zygomatic arch, the lateral orbital wall/rim, the inferior orbital rim/floor, and the lateral maxillary sinus wall. Find one component and go looking for the rest — they travel together.
A flattened cheek can be masked early by swelling, and a buckled but non-displaced arch is easy to skim past. Scroll the arch on every facial CT — an isolated zygomatic arch fracture can still trap the jaw, blocking the patient from opening their mouth.
Le Fort: when the face comes off the skull
This is the pattern people fear and misremember. René Le Fort figured out, with admirable Victorian commitment, that the midface separates along three reproducible planes. The unifying truth that saves you every time:
Every Le Fort fracture, by definition, crosses the pterygoid plates — the little wings of bone tethering the maxilla to the skull base behind. No pterygoid involvement, it isn't a Le Fort.
The three levels are about how much face detaches and at what height:
| Level | What detaches | Plane (in addition to pterygoids) |
|---|---|---|
| Le Fort I | The tooth-bearing palate, a "floating palate" | Across the lower maxilla above the teeth |
| Le Fort II | A pyramid of central midface, the "floating maxilla" | Through the inferior orbital rims and nasal bridge |
| Le Fort III | The whole face from the skull, craniofacial dissociation | Across the orbits and zygomatic arches |
In practice they're often asymmetric — one side Le Fort II, the other Le Fort I — because real faces rarely get struck perfectly head-on. So describe each side rather than forcing one tidy label.
What actually matters when you call it
Naming the fracture is the easy half. The half that changes management is the company it keeps.
For every facial fracture, run a quick checklist of the dangerous neighbors: is the orbit or optic nerve involved, is a muscle entrapped, is the airway threatened by a mobile midface, and is there active bleeding or a vascular injury near the skull base? The bone gets the eponym; these findings get the patient admitted.
And don't tunnel-vision on the face. High-energy facial trauma loves company elsewhere — intracranial injury, cervical spine fractures, and skull base or temporal bone trauma all ride along. Scroll up and out before you sign off.
If you remember one thing: the face breaks in patterns, the patterns point to predictable victims (eye, airway, brain, vessels), and your job is less about memorizing eponyms than about asking what got hurt because this bone did.