Far Eastern University – Nicanor Reyes Medical Foundation
Simple / Linear Fracture
Gross B – Correlative Anatomy of Head and Face
James Taclin Banez, M.D. (add. notes from Michael Capulong, M.D.)
HEAD LESIONS:
 Main problem of head lesions is the increase in intracranial
pressure
A patient with increased intracranial pressure usually has a fixed, dilated
pupil on the affected side. Since the parasympathetic fibers of CN III are
inactivated first during compression
I. Trauma
 Also known as head concussion
 The most common cause of head injury
 Can lead to skull fractures, hematomas and injuries to the brain
 The first thing to do in trauma is the ABC of medicine: Airway
(check if the passageway of air is clear), Breathing (check for
pulse and if the patient is breathing) and Circulation (check for
circulation by chest compression)
II. Skull Fractures
 The most common form of head injury
 Can cause hematomas and can directly damage the surface of
the brain
 If the cranial fossa is damaged or fractured, can cause lesions on
the cranial nerves
 Can be closed or open, linear or comminuted
 A presence or absence of depression can be observed
 Occult / evident
 Radiographic examinations are essential for evaluation
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A.
 Also known as hairline fracture
 Almost invisible in x-ray, but CT scan can be requested for
further evaluation
 These non-displaced fractures do not accompany other problems
most of the time
 Usually requires no specific treatment and heals by itself by
fibrosis
B. Depressed / Comminuted Fracture
 Fractures with visible injury and are usually caused by low
velocity injuries (a blow on the head by a baseball bat or
hammer)
 Edges of fracture line have been drive inward
 Involves brain injury
During surgery, trepanning or drilling a hole at the patient’s skull is
performed to release the intracranial pressure. If not performed, the
intracranial pressure can exit through the foramen magnum and cause
damage to the medulla oblongata
C. Compound Fracture
 Involvement of the overlying scalp
 This type of skull injury exposes the calvarium
 Warrants suturing to avoid contamination and infection
 Caused by hacking injuries to the head
D. Basal Fracture
 Happens when there is a direct blow to the top of the head, and
the direction of the force will go the base of the skull
 Similar to linear fractures, except that it involves bones at the
floor of the cranial vault
 Can also be an open type of fracture, wherein there is a violation
of the dura. This manifests as CSF leakage
 Otorrhea –leakage through the ear
 Rhinorrhea – leakage through the nose
III. Injury to the Meninges
 Can cause an increase in intracranial pressure in the form of
bleeding or edema (cerebral) secondary to bone fracture
A. Epidural Hematoma / Extradural Hematoma
 Presence of blood between the endosteum of the skull and the
dura mater
 Usually secondary to the tear of the middle meningeal artery
(rarely the vein)
 Occurrence: 1-3%
 Presence of skull fracture
When a conscious patient that suffered from trauma to the head
suddenly becomes unconscious, it is a sign of an increase in intracranial
pressure. This can also lead to coma. This sign is common for epidural
haemorrhages.
 Presence of blood between the dura and the arachnoid mater
 Secondary to blunt injury without skull fractures
 Usually venous in origin with a positive tearing of the cerebral
vein as it enters the superior sagittal sinus
 Hematoma usually located on the convexities of the cerebral
hemispheres
 Can be acute or chronic:
1. Acute Subdural Hematoma
 Usually associated with trauma, often with laceration
and contusion of the brain.
 Bleeding originates from a torn bridging vein
 Onset of symptoms: Fluctuating levels of
consciousness
2. Chronic Subdural Hematoma
 Less dramatic, and follows insignificant and forgotten
trauma
 Insidious onset
 Presence of confusion and inattention. Can rarely
cause seizures and coma
 Symptoms often attributed to other process.
 Often times called “Great mimicker”
C. Subarachnoid Hematoma

 If the medical emergency is not resolved or organized it can lead

to:
 Temporal lobe herniation
 Crushing of the midbrain
 Medullary compression
 Damage in the respiratory center which can lead to
respiratory arrest and eventually death
 Treatment: Surgical drainage
 Escape of blood into the subarachnoid space
B. Subdural Hematoma  Usually arterial in origin. 70% due to the rupture of saccular
aneurysm, for example, the rupture of the aneurysm of the
internal carotid artery
 Some is associated with skull fractures and cerebral lacerations
 Presence of meningeal irritation which cause severe headache,
stiff neck and loss of consciousness

There are two types of aneurysms: The saccular and fusiform

aneurysms. A saccular aneurysm is the most common type of aneurysm
and account for 80% to 90% of all intracranial aneurysms and is the
most common cause of nontraumatic subarachnoid haemorrhage.
These small, berry-like projections occur at arterial bifurcations and
branches of the large arteries at the base of the brain, known as the
Circle of Willis. The fusiform aneurysm is a less common type of
aneurysm. It looks like an outpouching of an arterial wall on both sides
of the artery or like a blood vessel that is expanded in all directions.

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IV. Injuries to the Brain:  Types:
A. Cerebral Concussion  Communicating
 Jarring of the brain with no accompanying defect and only  Ventricular pathway or flow of CSF is unimpeded but
manifestation is pain there is decreased CSF absorption of excessive
 Secondary to blunt head injury production, non-obstructive
 Transient loss of consciousness and usually short duration  Common among children
 If unconscious, complete recovery without neurologic deficits is  Non-communicating
expected within 6 hours  Obstructive type, most common type in adults
 Injuries due to acceleration and deceleration of the head,  Obstruction exerts extra pressure on the system
when the brain hits the stationary skull  Manifestations:
 Can occur at any age but most common among children, 0-2
B. Cerebral Contusion years old
 Area of haemorrhagic necrosis (can be epidural or subdural) is  Presents with an enlarged head, distended scalp veins, and
secondary to blunt force crushing or bruising the CNS tissue wide cranial sutures
 Common site is the surface of the brain, the pia mater is  Sun-setting sign – upper part of the iris is visible
stripped and torn  Transillumination test is positive
 Coup lesion: injury at the site of impact  Treatment:
 If contusion occurred near the pre-central gyrus, motor  Removal of etiology
function could be affected contralaterally, on the other  Shunting procedure
hand, if contusion occurred near the post-central gyrus,  Ventriculo-peritoneal shunt
sensory function is affected contralaterally  Ventriculo-pleural shunt
 Contrecoup lesion: injury at a distance from point of impact,  Ventruculo-atrial shunt
usually on the opposite side
 Due to inertia, since the opposite side of the brain is
affected, the paralysis may occur on the same side of the Le Fort Classification of Skull Fractures
lesion  Distinguishes skull fractures according to the plane of injury

C. Cerebral Lacerations A. Le Fort Classification I

 Tearing of neural tissue
 Associated with depressed skull fractures or gunshot wounds
(penetrating injury)
 Results in the rupture of blood vessels and bleeding into the
brain and subarachnoid space. Which can cause intracranial
pressure and cerebral compression

V. Hydrocephalus:
 Pathologic entity described as having increase in amount of
cerebrospinal fluid in the ventricular system
 Common to children ages 0-2 yeats of age
 Usually congenital in nature and mainly due to the increased
production of CSF  Horizontal maxillary fracture, separates the teeth from the
upper face
 Etiology:
 Superior to the alveolar process
 Congenital
 Aqueduct atresia or stenosis  Cross bony nasal septum and pterygoid plate of sphenoid
 Arnold chiari – a congenital herniation of the brainstem
and lower cerebellum through the foramen magnum
into the cervical vertebral canal
 Dandy Walker syndrome – a cystic malformation of the
th
4 ventricle of the brain resulting from hydrocephalus
 Neoplasm
 Acquired
 Infections meningitis
 Intraventricular and subarachnoid haemorrhage
 Neoplasm

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 B. Le Fort Classification II
 A pyramidal fracture, with the teeth at the pyramid base and
nasofrontal suture at its apex
 Fracture starts posterolaterally from the maxillary sinus to the
infraorbital foramina, lacrimals or ethmoids to the bridge of the
nose, superomedially
C. Le Fort Classification III
 Craniaofacial disjunction
 Fracture line passes through the nasofrontal suture, maxilla-
frontal suture, orbital wall and zygomatic arch
 Passes horizontally to the superior orbital fissures, ethmoid and
nasal bones
 Laterally through the greater wings of the sphenoid, lesser wing
of the sphenoid and fronto-zygomatic sutures
 Cranial nerves passing through the superior orbital fissure, along
with the optic nerve may be damaged
FACE LESIONS:
I. Mumps
 A highly contagious infection spread by a paramyxovirus.
 The virus can travel in the air through coughs and sneezes, it may
be on surfaces people touch, such as door handles or it can be
picked-up from cups, cutlery, bowls or plates.
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 The most common symptom of mumps is swollen salivary
glands, primarily the parotid gland in the neck
 Sometimes referred to as a 'hamster face' appearance. The
swelling can be on one or both sides of the neck
 Mumps can be prevented in 95% of cases by having the routine
MMR vaccination in childhood or later in life
To check if the patient has mumps or bacterial infection, press the
parotid gland inside the oral cavity, if pus exits through the oral vestibule
near the second molar then it is a bacterial infection, not mumps.
II. Periorbital Hematoma
 The eyelids is the thinnest skin on the whole body, but is highly
vascularized
 The person's vision is blurred, double, or lost in either eye and in
severe pain
 Intraorbital injury may also occur
 There is drainage or bleeding on the white part of the eye or
drainage from the eye.
 The eyeball looks abnormal
 Skin around the eye is split or there is a cut on the eyelid
 To treat symptoms: Apply ice to the area. Don't press on the eye.
 For pain, give acetaminophen (Tylenol). Don't give aspirin or
ibuprofen (Advil, Motrin), because they can increase bleeding.
III. Bell’s Palsy
 Causes paralysis or weakness of the muscles on one side of the
face
 Results from facial nerve paralysis that causes the affected side
of the face to appear flat, expressionless, or droopy, sensory to
the ear can also be affected
  Taste sensation and tear or saliva production can also be
affected
 Most cases are thought to be caused by the herpes virus that
causes cold sores. In most cases of Bell's palsy, the nerve that
controls muscles on one side of the face is damaged by
inflammation.
 Most people who have Bell's palsy recover completely, without
treatment, in 1 to 2 months. This is especially true for people
who can still partly move their facial muscles.
 Treatment with corticosteroid medicines (such as prednisone)
can make it more likely that you will regain all facial movement.
IV. Facial Lacerations
 A cut on the face
 Lacerations usually heal quickly, but they need special care to
reduce scarring
 It will take 1 to 2 years for the scar to lose its redness and to heal
completely
V. Nose Bleed
 Nosebleeds are common due to the location of the nose on the
face, and the large amount of blood vessels in the nose.
 The most common causes of nosebleeds are drying of the nasal
membranes and nose picking (digital trauma), which can be
prevented with proper lubrication of the nasal passages and not
picking the nose.
VI. Cleft Lip / Cleft Palate
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 A deformity of lip and palate resulting from an abnormality in
development of lip and oral cavity
 Failure of fusion of the upper lip and the palate
 Typically seen at birth
 Classification:
 Primary – involves the lips, nostril and anterior palate
 Secondary – involves the hard palate and soft palate
 Complete – if cleft lip extends into the nostril
 Incomplete – involves only upper lip without the nostril
 Most common seen are left, unilateral, complete with primary or
secondary palate
 Timing of surgery:
 Cleft lip – limited only by the general health of the patient
 Rule of 10 – must be met before surgery is done, this is vital
for the feeding of the infant patient
 10 g/dL of haemoglobin
 10th week of life
 10lbs (4.5 kg)
 Surgery is not done on younger patients because it entails
greater risk
 Cleft palate – 6-18 months before 2 years old, to aid in
feeding and prevent speech defects
 The longer the surgery is delayed, the more the
complications because the palate will undergo fibrosis
 Surgical repair
 Millard operation – use of rotation / advancement flap
 Secondary revision is frequently necessary
Undon qringao daor, gien undon!
"Don't find fault, find a remedy!"