62.3 Simpler methods for maxillary fractures

There are few easy methods for Le Fort fractures. If the patient is lucky enough to have an intact mandible, you can wire his broken maxilla to it. Packing his maxillary sinuses and repairing his orbital floor are beyond a district hospital.

Le Fort Type One fractures with an intact mandible

Alveolar fractures are quite common, so to be able to do anything for them is useful. Although they are much easier to fix if the patient has an intact mandible, you may be able to fix a mandibular fracture with an arch bar, and then proceed as if his mandible were intact.

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Figure 62.7: SIMPLER METHODS FOR LE FORT FRACTURES. A, interdental wiring holding a unilateral fracture in place. B, wire round the patient’s zygomatic arches holding a bilateral fracture in place. C, a Kirschner wire holding the central part of his face in place. D, this figure was drawn from a cast, and shows what can happen if you fail to reduce a severe maxillary injury. Note the gross malocclusion. The patient’s jaws will have to be refractured and reset. Aligning them would have been much easier at the time of the injury. E, a lumbar puncture needle has been passed medial to his zygomatic arch into his upper buccal sulcus, and was passed down it. F, the needle has been withdrawn. G, the needle is being passed lateral to the zygomatic arch. Kindly contributed by Susan Likimani and Andrew Curnock.

If he has a Le Fort Type One fracture on one side only, half his alveolus hangs loose on that side, as in A, Fig. 62-8. If his mandible is intact you can wire it to the intact half of his alveolus, so that it holds the fractured half reduced.

If his alveolus has fractured on both sides, and he has an intact mandible, you can wire his zygomatic arches on both sides to his mandible, as in B, Fig. 62-8.

Type Two Fractures

In some Type Two fractures the zygomatic arches are intact, but the bones of the centre of the patient’s face are displaced. You may be able to drill a Kirschner wire through one zygomatic arch, through the displaced central fragment of the face, and then out through the other arch.

WIRING THE ZYGOMATIC ARCH TO THE MANDIBLE

INDICATIONS Maxillary fractures with an intact mandible.

ANAESTHESIA Premeditate the patient well and use infiltration anaesthesia of his gums (A 6.3).

Fix wire eyelets to his teeth on both sides of his lowerjaw as in Section 62.10.

Protect his eyes as in Section 62.4. Push a blunt aspiration needle or large lumbar puncture needle through his skin just above his zygomatic arch and posterior to his outer canthus. Push the needle downwards behind his zygomatic arch into his superior buccal sulcus, as in E, Fig. 62-8.

Thread wire through the needle and then remove the needle, leaving the wire in his tissues (F).

Now pass the needle up from his buccal sulcus, superficial to his zygomatic arch, under his skin, to come out of the same hole in his skin as the wire (G).

Pass the other end of wire through the needle so that it emerges in his buccal sulcus. Remove the needle. You will now have a loop of wire passing round his zygomatic arch with both ends emerging in his buccal sulcus.

Repeat the process on the other side, and then join the wire loops to the eyelets that you have previously fixed to his mandible.