Trauma and Reconstruction of Facial Fractures
Core concepts
Master facial buttress anatomy and the Le Fort classification, zygomaticomaxillary complex fractures, orbital floor/blowout, naso-orbitoethmoid (NOE) injuries, and mandibular fracture patterns. Understand occlusion as the guide in mandible and midface repair, and the role of maxillomandibular fixation versus rigid internal fixation. Know indications for orbital exploration (entrapment, muscle restriction, enophthalmos, large floor defect) and the white-eyed blowout in children. Understand NOE classification by medial canthal attachment and the need for canthopexy. Know when to use primary bone grafting versus later reconstruction, and the timing of repair (early vs delayed with swelling).
Traps
Questions test missed injuries: cervical spine, orbital entrapment, and dental/occlusal disruption. Another trap is the pediatric greenstick pattern and trapdoor floor fracture causing bradycardia (oculocardiac reflex). Distinguish tripod zygoma fixation points and when one-point fixation suffices. Know that medial canthal tendon avulsion requires canthopexy, not just bone plating.
Worked example / rule of thumb
A child with nausea, restricted upgaze after blunt trauma and a minimally displaced floor on CT: suspect trapdoor fracture with entrapment-urgent exploration. Rule of thumb: restore occlusion first, buttresses second; entrapment is an emergency regardless of CT displacement.