Fractures of the Bones of the Face

IN reviewing the literature, very little can be found concerning fractures of this type. A certain number of authors, chiefly Bowen, have given the subject consideration, and this paper will deal with the methods as used in our practice. At this time, only the malar bone and its attachments and the zygomatic arch will be considered. Other positions about the head and neck are being studied, but, as yet, their value and practicability have not been sufficiently proved for presentation. A brief review of the anatomy shows the malar to be a rather heavy diamond-shaped bone with four articulations to structures of a much more fragile construction. These articulations are with the external angular process of the frontal, the great wing of the sphenoid, the superior maxilla, and the zygomatic process of the temporal. The zygomatic arch is a long process projecting from the lower part of the squamous portion of the temporal bone, that articulates with the zygomatic process of the malar. According to Da Costa and Scudder, the malar bone itself is rarely fractured. The fractures usually occur at its attachments, the zygomatic arch being frequently involved. The deformity in these fractures consists of a depression to the outer side of, and below, the eye. If this depression impinges upon the coronoid process of the inferior maxilla, there will be a limitation of the movements of the lower jaw. Occasionally, the swelling of the soft parts is sufficient to produce this symptom. If the orbit is involved, there may be a localized subconjunctival hemorrhage; and, if the infraorbital nerve is injured, there will he prickly sensations along its course—i.e., in the upper gums and in the skin of the cheek, nose, and upper lip. In demonstrating the fractures in the bones of the upper part of the face, a position practically the same as that employed by Waters in showing the antrum is used. In the first position, the patient lies on the abdomen with the nose and chin resting upon a cassette supported by a twenty-three degree angle board. The central ray is directed straight downward so that it passes through the center of the malar bone. In demonstrating the bones of the lower part of the face, especially the zygomatic arch, the head is placed the same as in the first position; the tube is tilted fifteen degrees toward the feet, and then moved toward the head of the table until the central ray passes through the mid-portion of the arch. All this work has been done on the Potter-Bucky diaphragm at a 32-inch distance with 75 to 85 K.V., 25 ma., 3½ to 5½ seconds exposure, through 1 mm. of aluminum filter. The lower voltages and shorter exposures are used in the first position, and the higher voltages and longer exposures in the second position. Case No. 1 (Fig. 5). A male, age twenty-four, was struck over the left malar by a blow from a fist.