The fractures discussed in this section are typically described as high-energy or high-velocity or high-impact injuries to the facial skeleton. The nasoethmoid complex (NEC) fracture is also known as the naso-orbital ethmoid (NOE) fracture, both names being attempts to describe the clinical and anatomic components of the bone injuries involved. These types of fractures occur when a force is directed primarily to the area of the root of the nose. The solid nasal root may or may not fracture, but frequently, the thin medial orbital wall bones behind the nasal root will be compromised (Stranc described this fracture as an “ethmoid crush”), allowing the nasal root to “telescope” inward into the area of the ethmoid sinuses. The loss of support of the lacrimal bones often results in disarticulation of the medial canthal ligaments (with or without bony attachments), thereby often resulting in lateral displacement of the medial canthal ligaments or “telecanthus.” The injury creates the appearance of hypertelorism, often called “pseudohypertelorism,” since the orbits themselves are not actually displaced laterally as the term hypertelorism implies. The term NEC fracture or NOE fracture refers to the fractures of the bones involved (Fig. 52.1).

The Le Fort III fracture refers to the most serious level of the Le Fort fracture series, otherwise known as the “craniofacial separation.” The Le Fort I, II, and III fractures were described by Rene Le Fort in 1901. They refer to primarily horizontal fractures that traverse the facial skeleton between the maxillary dentition and the upper face or cranium. The Le Fort III fracture breaks through the lateral and medial orbital walls, crosses the nasal root and nasal septum, and is completed by extending across the posterior floor of the orbits and the zygomatic arches, as well as the pterygoid plates posteriorly. This results in a complete separation of the midfacial bones from the cranial portion of the skeleton (Fig. 52.2).

The NEC fractures may occur together with or independently from the Le Fort III fractures.

In civilian life, most NEC and Le Fort III fractures are the result of high-velocity injuries as might typically be seen in motor vehicle accidents (particularly when seat belts are not worn and/or air bags are not deployed), industrial accidents, and direct assaults to the central face using heavy instruments, such as a pipe or baseball bat. Intracranial injuries may be associated, and a complete history, including loss of consciousness, should be elicited. Symptoms and/or signs of neurologic injury are common, and changes in vision may be present as well. Though difficult to determine when the nose is filled with blood, the possibility of anosmia should be considered.

Of course, other comorbidities should be considered as well. It is important to determine if drugs and/or alcohol played a role in the patient’s condition, as it may impact medical management and the timing of surgery. These issues may also affect the patient’s ability to cooperate with postoperative care.