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#CMF Manual of Operative CMF TRauma
#CMF Manual of Operative CMF TRauma
Maxillofacial
Trauma Surgery
Michael Perry
Simon Holmes
123
Manual of Operative Maxillofacial
Trauma Surgery
Michael Perry • Simon Holmes
Manual of Operative
Maxillofacial Trauma
Surgery
Michael Perry Simon Holmes
Regional Maxillofacial Unit The Royal London Hospital
Ulster Hospital Barts Health NHS Trust
Dundonald London
Belfast UK
Northern Ireland
UK
v
vi Preface
Michael Perry
Simon Holmes
Acknowledgements
Many people have contributed to this book both directly and indirectly.
Without their involvement this would not have been possible.
We would like to thank the following colleagues for providing clinical and
surgical images.
Dr. Niranjan Chogle (Consultant Anesthetist, Ulster Hospital, Northern
Ireland), for his images, expertise, and skills in percutaneous airway
techniques
Mr. Alan Patterson (Consultant Oral and Maxillofacial/Head and Neck
Cancer Surgeon, Rotherham General Hospital, England), for providing
images and advice in endoscopic repair of the mandibular condyle
Mr. Peter Ramsay-Baggs (Consultant Oral and Maxillofacial Surgeon,
Ulster Hospital, Northern Ireland), who provided an interesting assortment of
cases and varied techniques used in many chapters.
Depuy Synthes Medical Ireland, Tekno Surgical, and KLS Martin for pro-
viding images of their products and supporting production of this book.
We would also like to thank our past trainers and other colleagues, without
whom we may never had developed our interests, skills, and knowledge in
trauma care. As Isaac Newton once wrote: “If I have seen further it is by
standing on the shoulders of giants.”
And, finally, we would like to thank the many hundreds of patients (many
of whom remain anonymous) who have so kindly allowed us to use the pic-
tures we have taken. Without them this book would not have been possible
and it is to them that we dedicate this book, with our heartfelt gratitude.
vii
Manual of Operative Maxillofacial
Trauma Surgery
This manual is a brief overview of the much larger and more comprehensive
Atlas of Operative Maxillofacial Trauma Surgery by M Perry and S Holmes.
Both the volume of text and number of images shown here have been greatly
reduced to provide a more succinct and ‘portable’ version – a ‘quick refer-
ence’ guide to the management of facial trauma. The atlas itself is a larger text
with over 2,000 clinical images and illustrations, detailing most of the surgi-
cal procedures described here, step by step.
Introduction
ix
x Manual of Operative Maxillofacial Trauma Surgery
Many of the techniques outlined in this book will have modifications, or vari-
ations. Furthermore, management of some injuries is still very controversial,
as we have tried to point out. Although we have endeavoured to cover as
much ground as possible, we do accept that this book is by no means totally
comprehensive – probably no book ever will be. Nevertheless, we hope this
will form a useful foundation for some.
To get the most out of this book (and the atlas), the reader should ideally
have some basic knowledge of anatomy and an understanding of trauma care
and basic surgical principles.
Contents
xi
xii Contents
Extended Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Condylar Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Unilateral Condylar Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Bilateral Condylar Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Fracture-Dislocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Surgical Repair of Condylar Fractures . . . . . . . . . . . . . . . . . . . 49
Retromandibular Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Transparotid Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Extended Approach for Fracture Dislocation . . . . . . . . . . . . . . 51
Endoscopic Assisted Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Comminuted and Complex Mandibular Fractures . . . . . . . . . . 52
The Atrophic Mandible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
7 Fractures of the Middle Third of the Facial Skeleton . . . . . . . 55
Applied Anatomy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Le Fort Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Split Palate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Surgical Repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Maxillary Disimpaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Internal Fixation of the Midface . . . . . . . . . . . . . . . . . . . . . . . . 59
Le Fort I Access (Access to Lower Midface) . . . . . . . . . . . . . . 59
Split Palates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Le Fort II Access. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Le Fort III Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
External Fixation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
8 Fractures of the Cheek: The Zygomaticomaxillary
Complex (ZMC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Overview of Anatomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Clinical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Investigations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Initial Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Timing of Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Planning Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Closed Versus Open Reduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Gillies Lift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
The Malar Hook (Poswillo Hook) . . . . . . . . . . . . . . . . . . . . . . . . . 68
Isolated Arch Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Open Reduction and Internal Fixation. . . . . . . . . . . . . . . . . . . . . . 68
Frontozygomatic (FZ) Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Buttress Plate (Intraoral Access) . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Infraorbital (Inferior Orbital) Access. . . . . . . . . . . . . . . . . . . . . . . 70
Zygomatic Arch Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Arch Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Inverted Hockey Stick Exposure . . . . . . . . . . . . . . . . . . . . . . . . . . 71
xiv Contents
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Contributors
xix
Initial Assessment
and Management 1
of Life- and Sight-Threatening
Complications
For a more detailed review of this topic see Atlas of Operative Maxillofacial Trauma
Surgery by M Perry and S Holmes.
Injuries to the face vary widely in severity, from now a well-established concept, and when
the most trivial to those associated with life- available, local guidelines should always be
threatening complications. Although in most followed. As a general observation, the most
cases such complications are immediately challenging patients are those with associated
apparent, occasionally they can be concealed, head, torso, or spinal injuries, or those patients
or they can develop over a period of several who present in profound hypovolaemic shock,
hours. Airway obstruction from progressive without an obvious cause. However, even the
swelling is an example of this. Injuries to the most “straightforward” of cases can rapidly
face can either occur in isolation, or they can be deteriorate if occult (hidden) injuries remain
associated with significant injuries elsewhere unrecognised for too long. Injuries to the torso
on the patient, some of which may also go (especially the chest) can significantly affect
unnoticed initially. the timing of surgery.
Initial assessment and management can there- As surgeons, we need to be aware of all these
fore be very challenging, as all these variables issues—failure to recognise them may greatly
need to be taken into account. influence outcomes.
In some cases, the presence of coexisting From our perspective, “emergency care” in
injuries can have a significant effect on the facial trauma effectively means airway manage-
patient’s overall treatment. Not only can these ment, control of profuse bleeding, and the man-
affect our ideal goals in planning treatment, but agement of vision-threatening injuries (VTI).
they can also affect those of other specialties. The management of life-threatening head injuries
Even relatively “simple” decisions may not be as is outside our area of expertise and requires
straightforward as we would like (e.g., “should urgent neurosurgical intervention.
we intubate the patient before going to CT, or
wait and see what the scan shows?”). Such
decision-making is also influenced by local cir-
cumstances (available resources, clinical experi- Triaging Facial Injuries
ence, concern for other injuries, and need for
transfer). From a practical point of view, facial injuries can
A team approach is therefore of vital be broadly placed into one of four groups, based
importance. Protocol-driven management is on the urgency of treatment required.
injuries, which require careful assessment of vomiting, but any reduction in consciousness fur-
the mediastinum. Some injuries (e.g., carotid ther impairs protective airway reflexes.
and upper aerodigestive tract), are relatively Care must be taken if patients with facial inju-
uncommon and therefore may not be initially ries are positioned supine.
considered. From a maxillofacial perspective,
how do we rapidly diagnose a vision-
threatening injury requiring immediate inter- “Can I Sit Up?”
vention in the unconscious patient?
When facial injuries are present in supine patients
it is important to recognise the implications of
Craniofacial injuries complicate the overall repeated requests or attempts by the patient to sit
management of the multiply injured patient up. Patients may try to sit themselves forwards
because they present their own set of clinical and drool, thereby allowing blood and secretions
priorities. These need to be carefully bal- to drain from the mouth.
anced against injuries elsewhere, some of
which may take greater priority. Injuries else-
where may greatly influence the management
of facial injuries, notably timing of definitive
repair. A team approach is invaluable.
Vomiting in the Restrained Supine Fig. 1.3 Urgent orotracheal intubation following
Patient (Before Spinal Clearance) unexpected vomiting in an awake patient with
severe facial injuries
Vomiting puts the airway immediately at risk,
especially in patients who are immobilised on
a spine board. All patients are at risk of this,
but those with facial injuries are at greater risk. intubation can sometimes be easier than anticipated
Early warning signs may include repeated in extensive fractures. This is because the
requests or attempts by the patient to sit up. mobile facial bones can be gently displaced by
Difficulty arises in deciding which patients are the laryngoscope, providing an adequate view
at such a high risk of vomiting and pulmonary of the vocal cords. Difficulty in visualising the
aspiration, that they should be urgently anaes- cords is more likely when there is ongoing
thetised and intubated to secure the airway. If bleeding and swelling of the pharynx and base
vomiting does occur, a clear and coordinated of the tongue. Nasotracheal intubation is gener-
plan of action is necessary. Senior anaesthetic ally regarded as potentially dangerous in the
assistance is therefore usually advisable to presence of anterior cranial base fractures,
evaluate the risks and benefits of intubation. although this assumption has been challenged
in the literature. Ultimately the final choice of
technique will be made by the anaesthetist. As
Definitive Airways surgeons we should be prepared to secure a sur-
gical airway if necessary.
These may be required if there is doubt about
the patient’s ability to protect their own airway.
The choice includes orotracheal intubation, Emergency Surgical Airways
nasotracheal intubation, and surgical cricothy-
roidotomy. All are relatively safe in experi- Surgical airways are occasionally required
enced hands, even in the presence of an unstable when it is not possible to safely secure the air-
cervical spine injury. way by any other means. In an emergency situ-
Orotracheal intubation with inline cervical ation, these include needle cricothyroidotomy
immobilisation is usually the technique of and surgical cricothyroidotomy (also known as
choice in the majority of cases. Surprisingly, cricothyrotomy).
6 1 Initial Assessment and Management of Life- and Sight-Threatening Complications
Figs. 1.4 and 1.5 Surgical cricothyroidotomy. The skin is incised and the subcutaneous tissues are bluntly dis-
sected to expose the C-T membrane immediately below. The incised membrane is opened with either the handle
of the scalpel or a spreader. The tracheostomy tube (or endotracheal tube) is then placed under direct
visualisation
Breathing
Figs. 1.7 and 1.8 Nasal packing using a urinary catheter. Two catheters are passed backwards through each
nostril, parallel to the palate and their ends grasped and withdrawn out the mouth. They are then inflated with
sterile water or saline and gently guided back into the mouth and gently wedged in the nasopharynx. The nasal
cavity is then packed. If skull base or orbital fractures are suspected, this needs to be packed lightly
Figs. 1.9 and 1.10 Carotid exposure. Following skin incision and exposure of sternomastoid muscle, the
muscle is retracted to expose the carotid sheath. This is then opened to expose the artery and its branches
Vision-Threatening Injuries 9
Figs. 1.13 and 1.14 Lateral canthotomy with lateral canthal tendon division can be performed under local
anaesthesia. The lateral canthus is detached using sharp scissors. When this is successful the globe “pops” for-
ward. Formal evacuation of the haematoma is then carried out under a general anaesthesia
occur as a result of acute bleeding within the can injure the nerve as it passes through the rela-
orbit— retrobulbar haemorrhage (RBH). This tively thick bony canal into the orbit. Deceleration
is considered to be a surgical emergency that injuries and blunt trauma to the face and head are
(depending on the patient’s general condi- the common causes of TON.
tion and likelihood of salvaging vision), may Diagnosis of traumatic optic neuropathy is a
require immediate decompression. Following clinical one. Visual loss is usually profound and
immediate lateral canthotomy and cantholysis, almost instantaneous, but it can be moderate and
medical measures are instituted while prepar- delayed. Clinical findings that suggest an optic
ing the patient for surgery. nerve injury include decreased visual acuity and
However, it is worth remembering that not all a relative afferent pupillary defect.
cases of “tense” proptosis following trauma are Traumatic optic neuropathy needs immediate
due to RBH. Previous reports have shown that ophthalmic referral. Treatment has long been
many cases of proptoses are secondary to oedema controversial and may be medical or surgical.
within the retrobulbar tissues. This has major Medical treatment aims to reduce the oedema
implications in how patients are managed. and inflammation that contributes to nerve isch-
Therefore the term orbital compartment syn- aemia. There has been a presumed role for high-
drome (OCS) is very useful. This is more accu- dose intravenous corticosteroid in the treatment
rate and conveys the sense of urgency when of TON, but there is now a growing consensus
communicating with colleagues unfamiliar in the against this, with recent papers suggesting that
management of facial trauma. steroid use may actually be contraindicated. The
role of surgical decompression is even more con-
troversial. Surgical approaches include transeth-
Traumatic Optic Neuropathy moidal, transcranial, or via a lateral orbitotomy.
What Is the Optimal Time to Repair (particularly in complex cases) toward wide sur-
Facial Injuries? gical access, precise anatomical reduction and
when necessary, bone grafting. Unfortunately,
The past 20 years or so we have seen major comprehensive repair of extensive facial injuries,
changes in the management of trauma patients, if undertaken too early in the multiply injured
and in some specialties, long-standing practices patient, could result in potentially very sick
are now being challenged. In the general trauma patients, or those with unrecognised injuries,
literature there is now debate over the relative mer- undergoing prolonged surgery at a time when
its of “early total care” versus “damage control” in they would do better in intensive care. However,
the management of the multiply injured patient. if we simply leave all our patients for several
With severe injuries it is argued that the main weeks before we treat them, the development
priority should initially be the rapid control of of late complications (notably respiratory infec-
haemorrhage and the elimination of significant tions/failure and sepsis) may result in patients
contamination to prevent septic shock. This is becoming too sick to undergo surgery. We may
termed “damage control” and may involve rapid then miss the opportunity of treating them alto-
external fixation (e.g., of the pelvis), and packing gether. Surgery is also technically more chal-
the abdominal cavity. Because the patient is in lenging when delayed, as the healing process is
such a severe condition, the added physiological well underway. Consequently it becomes much
insult of surgery is kept to a minimum. Prolonged harder to mobilise and precisely reduce the tis-
immediate surgery may increase the risk of mul- sues, sometimes necessitating wider exposure
tiorgan failure. Following such “damage limita- and a longer procedure.
tion surgery,” the patient is then transferred to the The optimal time to definitively repair facial
intensive care unit. Complex surgery is deferred a fractures is therefore a delicate “balancing act”
few days until the patient is as well as possible. that needs to take into account all the patient’s
Certainly in those patients who present “in extre- injuries and their physiological status. Better out-
mis,” this would seem a logical approach, but comes may be possible with earlier or immediate
with less severely injured patients, the benefits repair, but this needs to be balanced against the
are less clear. patient’s overall condition. Blood loss is a key
In the maxillofacial literature, there has been element to this. Significant haemorrhage sets off
a move towards early and total repair of facial a potentially lethal chain reaction, starting with a
injuries. There has also been a clear move “lethal triad” of acidosis, hypothermia, and
tion. In essence this is an oral endotracheal (ET) and skin incision. This allows the tube to lie
tube that exits the patient through the floor of the alongside the tongue in the lateral floor of
mouth and neck, rather than through the oral aper- the mouth. This is a matter of personal
ture. Choice of tube is important. This is required to preference.
undergo a sharp bend and therefore must not kink. Submental intubation requires careful fore-
A variant of this approach is to bring the thought, particularly with regards to choice of
tube out through a more laterally sited tunnel endotracheal tube.
Figs. 2.2, 2.3, 2.4 and 2.5 Submental intubation. A full-thickness skin incision, large enough to allow the
passage of two retractors and the tube (approximately 2 cm in length) is made in the submental region. Blunt
midline dissection then proceeds towards the midline of the floor of the mouth. A second midline incision is then
made in the mucosa of the floor of the mouth. Further blunt dissection then completes a tunnel, passing through
the floor of the mouth and out through the submental incision. With the patient fully oxygenated, the endotra-
cheal tube is temporarily disconnected from the anaesthetic circuit and its end gently fed through the tunnel
16 2 Timing Repair and Airway Considerations
Tracheostomy
Figs. 2.7, 2.8, 2.9 and 2.10 Percutaneous tracheostomy. A needle is passed through the tracheal wall into the
lumen. Once the needle and sheath are confirmed to be in the tracheal lumen, the needle is removed, leaving the
sheath. A guidewire is then passed through the sheath. Using dilators the hole is serially dilated until large
enough to pass the tracheostomy tube
Tracheostomy 17
Figs. 2.11, 2.12, 2.13 and 2.14 Tracheostomy. A horizontal full-thickness skin incision is made, approxi-
mately midway between the cricoid ring and the sternal notch. Blunt midline dissection is then performed,
heading toward the trachea. The strap muscles are separated using retractors. The thyroid isthmus is often
encountered during a tracheostomy. This can either be retracted upward or divided and is a matter of personal
choice. Enough of the trachea needs to be exposed for an adequate sized fenestration. A number of openings
into the trachea have been described. If the endotracheal cuff has not popped it is then slowly deflated by the
anaesthetist and the endotracheal tube gradually withdrawn until its distal end is just above the hole in the tra-
chea. The tracheostomy tube is then gently inserted. Its cuff is then inflated and it is connected to the
ventilator
18 2 Timing Repair and Airway Considerations
Tacking Sutures
With heavily contaminated wounds, meticu- Bleeding from the Nose (Epistaxis)
lous debridement and copious irrigation are
required before closure or dressing. Many anti- Most bleeding arises from either Kiesselbach’s
septic dressings exist. Proflavin is a useful plexus or mucosal lacerations, usually from the
choice. anterior part of the nose. Posterior epistaxes
Figs. 3.3 and 3.4 Extensive damage to the ear dressed using proflavin
Temporary Splinting of Teeth 21
Figs. 3.5 and 3.6 Splintage using wire and dental adhesives
22 3 Useful “First Aid” Measures and Basic Techniques
not necessarily the fractures). This allows a fractures treated with IMF need to be rigidly sup-
“tailor-made” approach for each fracture. Not all ported, notably fractures of the condyle.
Figs. 3.9, 3.10, 3.11, 3.12, 3.13, 3.14 and 3.15 An assortment of IMF devices
24 3 Useful “First Aid” Measures and Basic Techniques
In both orthopaedic and maxillofacial surgery 1. To adequately (or anatomically) reduce the
a number of basic principles are commonly fractures
shared. 2. Adequately stabilise them to allow healing
3. Restore pre-injury function (and aesthetics in
the face)
Shared Principles in Orthopaedic and 4. Avoid complications
Maxillofacial Trauma A number of treatment options are usually
General available for most fractures. Success of fracture
Advanced Trauma Life Support principles management depends not only on how well the
Multidisciplinary care bones are repaired, but also on the condition of
Fracture related the overlying soft tissues. The worse the blood
Reduction, immobilization, and restoration supply, the greater the chances of infection,
of function nonhealing, and bone loss. Excessive move-
General move towards internal fixation in ment across the fracture also has an adverse
many fractures effect in healing by preventing vascularisation
Indications for external fixation of the bone fragments.
The relationship between excessive move-
ment, poor union, and infection
Management of soft tissues
Importance of the soft tissues in the success Rigid and Semirigid Fixation
of fracture healing
Importance of debridement, preventing In the strictest sense, “rigid” fixation means
infection, and maintaining vascularity that there is no movement whatsoever across
the fracture site. This produces such a level
of stability that direct bone healing can take
place. Rigid fixation therefore requires strong
The main aims of fracture management in both “load bearing” fixation devices. “Semi-rigid”
orthopaedics and maxillofacial surgery can be fixation is where fixation across a fracture is
summarised as follows: sufficient for it to heal, although a variable
Figs. 4.1 and 4.2 Compared to the limbs, the head and face are extensively vascularised. Despite complete detachment
from the soft tissues, these bone fragments can still be repaired and returned to the patient, with a very good chance of
healing
Lag Screws
Outer cortex
overdrilled
Figs. 4.3 and 4.4 Lag screw principle. Note the proxi-
mal fragment (nearest the screw head) does not engage the
screw. This allows compression. If the screw engages both
fragments, it is called a “positional screw”
28 4 Principles of Fracture Management
Figs. 4.5, 4.6, 4.7 and 4.8 Rigid fixation is an unforgiving technique but very useful in the repair of comminuted
mandibular fractures. It requires an extraoral incision. The fractures are initially reduced (with IMF) and the upper
fractures reduced and stabilised using conventional adaptive plates. A malleable template is then used to determine the
contour. The rigid plate is adapted to that. If not contoured precisely, anatomical reduction will not be possible. Drill
guides are necessary to allow precise placement of bicortical screws
Applying Semirigid Fixation (Miniplates) 29
Figs. 4.9 and 4.10 With posterior fractures of the mandible most repairs are undertaken through the mouth. The frac-
ture is anatomically reduced either with IMF or a hand-held reduction. The miniplate may be adapted and positioned
along “Champy’s line”. Variations are common. Both a transbuccal technique and “Propeller twist” are acceptable
alternatives
Figs. 4.11, 4.12, 4.13 and 4.14 With anterior fractures of the mandible most repairs are undertaken through the
mouth. A plate is adapted and screwed to one side of the fracture. The fracture is anatomically reduced and the remain-
ing screws placed. Following this a second plate is positioned to resist torsional forces. The further these plates are
apart, the better the mechanical advantage
30 4 Principles of Fracture Management
Fractures involving the enamel only are usually Treatment includes smoothing any sharp edges
slightly tender and may not have any obvious and relieving any occlusal pressure. Cracks can
signs of injury. Cracks may be visible using a be sealed with an appropriate bonding agent or
bright light to transilluminate the crown. composite.
When dentine is exposed, the tooth is typi- When the pulp is exposed, it must be care-
cally tender to touch and exposure to the fully managed. These teeth are very tender
air. The exposure should be gently cleaned and the pulp is seen as a pink or red spot
and an appropriate liner placed to seal off at the base of the defect. Fractures exposing
the dentinal tubules. The residual defect the pulps of teeth usually require pulp cap-
should then be sealed with a bonded com- ping, partial pulpectomy, or root canal treat-
posite material, or suitable alternative. ment, depending on the extent of exposure.
Figs. 5.3 and 5.4 Crown fracture extending into coronal third of the root. These fragments tend to be quite loose and
need to be handled carefully
The Avulsed Tooth 35
Mobile root fractures may require splinting for This is painful inflammation around the apex of
up to 12 weeks to enable union of the fracture. a tooth that usually occurs following occlusal
Vitality testing can be unreliable for up to 6 trauma. It can occur in vital, nonvital, and endodon-
months. However, loss of vitality usually indi- tically treated teeth. The tooth may be very sensi-
cates that the pulp has become necrotic. In these tive to touch. Initial management involves occlusal
cases, root treatment should be performed. adjustment to relieve it from repeated trauma. Anti-
inflammatory drugs should be prescribed.
Luxated Teeth
Storing Teeth During Patient Transfer Avulsed adult teeth should be replanted as
Patient’s buccal sulcus soon as possible after the injury and
Milk splinted for 7–10 days. Root canal treat-
Hartmann’s solution ment should be considered after removal of
Saline. the splint. This does not apply to deciduous
teeth. Replanting a deciduous tooth may
damage the underlying developing perma-
If the tooth has been dry for 20–60 min, some nent tooth
authorities recommend first soaking it in a bal-
anced salt solution for 30 min. If it has been dry
for more than 60 min it has been suggested to first Splinting Teeth
soak it in citric acid for 5 min, then in 2 % stannous
fluoride for 10 min, and finally in doxycycline for Many types of splint are available for supporting
5 min before reimplantation is attempted. Other displaced and fractured teeth.
reported treatments include gently brushing the
necrotic tissue from the root surface and soak-
ing it in topical fluoride for 15 min. Some stud- Common Methods of Splinting Teeth
ies have shown that when a tooth has been out The use of etched enamel retained composite
of the mouth for longer than 60 min, immediate The use of polymethacrylate reinforced
reimplantation is no longer required. Root canal with wire or nylon
treatment of the tooth can therefore be performed Vacuum-formed polyvinyl splints
on the tooth before it is put back.
Figs. 5.6, 5.7, 5.8 and 5.9 Commonly used splinting techniques
Dentoalveolar Fractures 37
Mastoid
process
(temporal
bone)
Styloid
Digastric process
fovease Digastric muscle
(posterior belly)
Digastric Mylohyoid muscle
muscle
Fig. 6.1 The muscles (anterior Fascial loop for
of mastication and belly) digastric tendon
suprahyoid muscles play Hyoid bone
an important role in Thyroid cartilage
fracture displacement in Infrahyoid
the mandible musculature
Clinical Examination
Numbness of the lower lip is a useful sign. Approximately half of patients with a man-
This may signify stretching of the inferior alveo- dibular fracture will have multiple fractures
lar nerve as a result of fracture displacement. present. In about 10 %, three or more sites
However, numbness can also occur in the absence will be involved. Therefore, if you see one
of a fracture. Sublingual haematoma is highly fracture, look closely for another.
suggestive of a fracture.
Management 41
Figs. 6.8, 6.9, 6.10 and 6.11 Following an initial mucosal incision the terminal branches of the mental nerve
are often quickly identified. Careful dissection isolates the nerve which is protected throughout the procedure.
Periosteal elevation exposes the anterior fracture. This can be easily manipulated into the reduced position. It is
then plated. Following fracture repair the wound is closed in layers. A supportive dressing for 10 days post-
operatively helps support the soft tissues
Management 45
Figs. 6.12, 6.13, 6.14 and 6.15 Following incision a full-thickness mucoperiosteal flap was raised. The frac-
ture could be easily reduced. The plate was secured to the posterior fragment, approximating to Champy’s line.
With the occlusion firmly held in place and the fracture reduced, the remaining screws were placed
Figs. 6.18 and 6.19 For midline anterior fractures the risk of injury to the facial nerve is relatively low. An
incision is placed in a suitable skin crease in the submental region, alongside the lower border. Dissection then
proceeds through the underlying platysma muscle, down to the periosteum, which is then incised and elevated
Figs. 6.20 and 6.21 With posterior approaches to the lower border, the likelihood of nerve injury increases and
greater care is required. This approach is very similar to that when removing a submandibular gland (sometimes
referred to as a Risdon incision). The incision can be placed low down in the neck, “two finger-breadths” below
the lower border of the mandible
Management 47
This may be required in comminuted fractures External fixation is essentially a “blind” and
involving much of the lower border. By their very imprecise technique (in that the fractures are not
nature, these sorts of injuries will often be very directly visualised). Nevertheless, combinations
swollen and a surgical airway may be required. of closed techniques (external fixation together
Figs. 6.22 and 6.23 Extended access. A long skin incision approximately parallel to the lower border is deep-
ened by blunt dissection using the combined steps of the anterior and posterior approaches just described
Fracture-Dislocation
Retromandibular Approach
Occasionally the condylar head may dislocate
out of the articular fossa following fracture. This In the example shown, a retromandibular
usually requires open reduction. These cases approach was chosen, since this appeared to be
need to be approached with caution. Comminution the “shortest route” to the easily palpable fracture
is commonly associated and makes repair of the condylar neck.
Figs. 6.25 and 6.26 CT evaluation of condylar fractures can be very useful. When viewed from behind, the dislocated
head is clearly fragmented. Repair would be very difficult for the inexperienced
50 6 Mandibular Fractures
Figs. 6.27, 6.28, 6.29 and 6.30 Several skin incisions are possible (linear or curved). All are sited just behind the
palpable neck of the condyle. As the flap is raised, the anterior branch of the great auricular nerve is sometimes encoun-
tered. Ideally this should be preserved if possible. The tail of parotid is gently retracted forward to expose the masseter.
This is incised along the posterior border and the periosteum elevated. Two plates are required for satisfactory repair
Figs. 6.31 and 6.32 This fracture is high and therefore not easily accessible through a retromandibular incision. The
skin incision is made in a suitable skin crease. Blunt dissection exposes the parotid fascia which is then opened by
scalpel or scissor. Tenotomy scissors are used to dissect through the parotid gland. One or more branches of the facial
nerve are frequently encountered. These are gently retracted. Following periosteal incision and elevation, the fracture is
identified
Figs. 6.35, 6.36, 6.37 and 6.38 Comminuted and complex mandibular fracture repaired extraorally
54 6 Mandibular Fractures
Figs. 6.39 and 6.40 Patients’ dentures or gunning splints can be used to stabilise the mandible
Figs. 7.1 and 7.2 A transilluminated dried skull showing “struts” of thick bone spanned by much thinner sheets of
bone. The struts or “buttresses” are arranged to resist functional forces
Fig. 7.3 Le Fort fracture pattern. Le Fort I (left), Le Fort II (middle), and Le Fort III (right)
Clinical Examination
Split Palate
Fig. 7.4 Split palate (note differing levels of inci-
Midline or segmental splits of the palate occur sal edges)
following high-energy impacts and are often
associated with widespread fractures of the mid-
face. They rarely occur in isolation. If the palatal
fragments are separated laterally they can some- during repair, the buttresses may be plated in the
times act as a wedge, displacing the zygomatic wrong position, resulting in an increase in the
buttresses laterally as well. If this is not recognised transverse width of the face.
58 7 Fractures of the Middle Third of the Facial Skeleton
Although plain films (occipitomentals [OMs]) Meticulous attention to the buttresses is the key
may provide some useful information, patients to successful repair of midface fractures. Not
with suspected midface fractures should ideally only are they important in establishing the three-
undergo CT scanning of the face. dimensional shape of the face, but they are often
Pure Le Fort fractures are rarely seen today. the only bones thick enough to securely support
Their precise diagnosis can be very difficult, plates and screws. If the buttresses are severely
although this is not essential. The true value of comminuted and cannot be repaired, bone graft-
CT is in determining the presence of “deep” or ing may be required.
occult injuries—those that may not be apparent Open reduction and fixation of the midface is
on clinical examination. It is important to remem- usually required in the majority of significantly
ber that disimpaction and manipulation of the displaced fractures. However, in patients in
midface can potentially manipulate deep, mobile whom the maxilla is undisplaced and stable, or if
fragments around the skull base and optic nerve. the patient is unfit for surgery, nonoperative treat-
ment may be appropriate. If the maxilla is dis-
placed in an edentulous patient, a new denture
may be a simpler and safer option once the frac-
ture has healed.
Maxillary Disimpaction
Figs. 7.8 and 7.9 Access to the lower midface can be achieved intraorally. This is the same incision used in
orthognathic surgery, when undertaking a Le Fort I osteotomy. Through this incision, the entire midface can be
exposed. Further exposure is possible by converting this into a “midface degloving incision”
60 7 Fractures of the Middle Third of the Facial Skeleton
In some cases, splits in the palate need reduc- Access to a Le Fort II fracture requires the same
tion and fixation. The tightly bound palatal intraoral approach as for a Le Fort I fracture (to
mucosa is usually torn, providing access. Plates access the buttresses). It also requires access to
may need to be removed at a later date, as they the bridge of the nose and/or infraorbital rims.
can become exposed, but this is an acceptable
compromise if the transverse facial width is
restored.
Remember to pay close attention to the nasal comminution. In such cases, the patient’s occlu-
septum. This is often fractured or deformed, result- sion is used to align the fractures, which are then
ing in loss of nasal projection. Following fixation of immobilised by fixing them to the cranium or
the Le Fort fracture, the nasal septum should be frontal bone. External fixation is generally car-
inspected and if necessary manipulated and splinted. ried out using supraorbital pins or a halo frame
connected to the maxilla with a bar. However,
this method has largely been superseded by inter-
Le Fort III Access nal fixation using plates.
External Fixation
Figs. 8.2 and 8.3 Campbell’s lines are a well-known visual aid to assess for steps and asymmetries. These are placed
along or parallel to the natural boney curvatures seen on the OM views. The displaced fracture of the left zygoma then
becomes readily apparent (especially along the arch and buttress in this case)
Planning Repair 65
a b c
Fig. 8.4 CT assessment starts with visualisation of the scan in the axial plane (a). The scans are viewed serially cranial
to caudal. This allows accurate assessment of the anteroposterior projection of midface and facial width. Fracture exten-
sion into the orbital floor is best assessed in the coronal plane (b). Sagittal views define the anterior and posterior mar-
gins of the orbital floor injury (c). Note the extensive right orbital floor component. Three-dimensional reformatting
now makes interpretation so much simpler
Planning Repair
Fig. 8.5 Extensive surgical emphysema in a patient who Indications for repair are shown.
repeatedly blew their nose following injury. In view of its
extent, a chest radiograph was requested. This showed
subcutaneous and mediastinal extension with “streaking” Indications for Repair of Fractured Zygoma
and outlining of the pericardium Facial deformity
Loss of lower eyelid support
Ocular dystopia
Timing of Repair Limitation of mandibular opening
Sensory nerve deficit thought to be caused
The vast majority of patients do not require by nerve compression
urgent intervention and can be reassessed as
66 8 Fractures of the Cheek: The Zygomaticomaxillary Complex (ZMC)
Figs. 8.6 and 8.7 In these two cases the fractures have “hinged” medially across their respective FZ sutures. The but-
tresses are stepped but will be attached to the periosteum. Closed reduction could be attempted, but fixation may be
required
Gillies Lift 67
Closed reduction techniques include: muscle. It passes inferiorly and is attached to the
• Temporal approach (Gillies lift) zygomatic arch. Therefore, any instrument
• Percutaneous or “Malar” hook (sometimes passed inferiorly, deep to this layer will
referred to as “Poswillo”) automatically pass underneath the zygoma and
• Eyebrow approach (zygomatic elevator) can therefore be used to elevate it.
• Carroll-Girard screw (now more of historical The success of this technique relies in
importance) part on the fact that the periosteum envelop-
• Intraoral approaches (via upper buccal sulcus) ing the fractures remains largely intact.
Intrinsic stability of any reduced fracture
requires intact periosteum and successful
Gillies Lift interlocking (“meshing”) of the fragments.
This technique therefore works best with
The Gillies lift is a versatile procedure. Its prin- isolated and simple depressed fractures of
ciple is simple. The temporalis fascia is a rela- the arch, or “en bloc” fractures of the ZMC
tively unyielding layer that covers the temporalis without comminution.
Figs. 8.8, 8.9, 8.10 and 8.11 Gillies lift. An incision is made through the skin. This is followed by blunt dis-
section onto the temporalis fascia. The temporalis fascia is then incised. A Howarth periosteal elevator is initially
passed deep to the fascia. It is then replaced by the definitive elevator. While an assistant steadies the head, the
elevator is lifted, (not levered against the skull)
68 8 Fractures of the Cheek: The Zygomaticomaxillary Complex (ZMC)
Figs. 8.12 and 8.13 Malar hook. The surface marking of the incision is seen here. The incision should lie
around the maximum projection of the zygoma. A small stab incision is made using a scalpel blade. The hook is
passed through the skin until it is felt to engage the undersurface of the zygomatic prominence. The bone should
always be fully engaged by the hook prior to elevation. Be careful in comminuted fractures
Following removal of the elevator, the tempo- periosteum. Provided that there is no separation
ral incision can be closed. A forced duction test at the fracture sites, these are usually stable on
should also be undertaken. elevation. Instability of the arch should be antic-
ipated if there are multiple fragments, manage-
ment is delayed more than 2 weeks, or if there is
The Malar Hook (Poswillo Hook) separation or telescoping of the fracture sites
indicating tears of the periosteum. In most cases
The malar hook technique is a very quick way of the depressed arch can be simply elevated via a
elevating a depressed fracture of the zygoma, Gillies approach. The success of closed
through a percutaneous stab incision on the treatment again depends on interfragmentary
cheek. It can also be used to elevate the bone locking.
through a transoral incision, prior to osteosynthe-
sis. Its advantage lies in the speed in which eleva-
tion can be achieved and its minimalistic Open Reduction and Internal
approach. This technique works best in simple Fixation
“hinged” fractures.
This has a number of advantages. Exposure of
the fractures allows for very accurate reposition-
Isolated Arch Fractures ing of the anatomy. Fixation with miniplates
affords greater stability and confidence in the
These are common injuries, often resulting from repair.
relatively low-energy mechanisms. Most inju- The various sites of repair must be considered
ries are V-shaped in nature with an intact in three dimensions, weighing up the pros and
Frontozygomatic (FZ) Access 69
cons of accessing and repairing each site. A few 4. Arch repair will establish the anteroposte-
key points are: rior positioning of the cheek prominence.
1. Usually the FZ suture is fractured in such a However, it requires an extended approach,
way that accurate reduction will be possible. which may a problem in advanced male pat-
Repair of a disrupted FZ suture reestablishes tern baldness, alopecia, or in patients prone to
the vertical dimension of the cheek. hypertrophic scarring.
2. Repair or alignment of the infraorbital rim Not all patients require fixation at all sites.
will correct and verify the transverse position Relatively few do. A stepwise approach is there-
of the bone, but carries a risk of eyelid distor- fore needed in some cases. Sequencing is a mat-
tion and palpable Plates. ter of choice.
3. Repair of the zygomatic buttress intraorally,
although very effective, can be technically
difficult. Frontozygomatic (FZ) Access
Figs. 8.14, 8.15, 8.16 and 8.17 Incision marked in a suitable skin crease. The mobile skin allows surprisingly
extensive access through a small incision. The periosteum is incised and elevated. The fracture is reduced and
plated
70 8 Fractures of the Cheek: The Zygomaticomaxillary Complex (ZMC)
Figs. 8.18, 8.19, 8.20 and 8.21 Access can be achieved relatively easily through a small incision placed in the
vestibular sulcus, just above the attached gingiva. It is important to leave enough of a cuff to allow tension-free
closure. If the incision is extended too far laterally, the buccal fat pad may herniate through the wound. The
periosteum is incised with a scalpel blade and the periosteum carefully elevated from the buttress
Although not a preferred routine incision (due In situations where the arch is bowed or buckled
to possible eyelid distortion), this approach (but the ends of the fractures are in contact), it is
may nevertheless be required if exploration or likely that the enveloping periosteum is mostly
repair of the orbital floor is required. This intact. In such cases, fixation of the arch itself is
approach provides good visualisation of the lat- often not required, so long as adequate fixation is
eral orbital wall (a key site in the assessment of placed elsewhere (notably the FZ suture and
accurate reduction. In some cases it may even intraoral buttress). The more deformed or com-
be possible to plate the lateral wall through this minuted the arch appears to be, the more likely it
incision). is that fixation will be required.
Inverted Hockey Stick Exposure 71
Figs. 8.22, 8.23, 8.24 and 8.25 The inverted hockey stick incision extends from the preauricular region into
the temporal scalp. Dissection proceeds down the avascular plane just in front of the tragus. This will reach the
base of the arch, where the periosteum is incised. The skin incision is then extended upwards into the scalp and
deepened to expose the temporalis fascia. This is then incised. This entire skin/fascial layer is reflected forwards
to begin to expose the superior aspect of the arch
72 8 Fractures of the Cheek: The Zygomaticomaxillary Complex (ZMC)
Figs. 8.27, 8.28, 8.29 and 8.30 This technique follows the same principles as the transcutaneous approach to
the condyle. The incision is marked in a suitably sited skin crease, approximately 1.5 cm in length. Following a
full-thickness incision of the skin only, deeper dissection then proceeds by blunt dissection. Once the arch and
fracture have been clearly identified, the periosteum is incised and elevated. The fracture can then be repaired
Orbital Fractures
For a more detailed review of this topic see Atlas of Operative Maxillofacial Trauma
9
Surgery by M Perry and S Holmes.
Applied Anatomy
Blowout Fractures
Figs. 9.3 and 9.4 The “posteromedial” bulge is a key site in repair. The floor is not flat, but has a number of gentle
curves
Clinical Assessment
number of injuries to the bony orbit are associ- damage following orbital trauma. Any damage to
ated with injuries to the globe itself. Always these muscles (or the cranial nerves that innervate
check the visual acuity and seek ophthalmic them) has an impact on the “laws of eye move-
advice if you are not sure. If a penetrating injury ments” and subsequently the patient’s ability to
to the eye is suspected from the history, pressure keep their eyes working in a coordinated fashion.
should be avoided. A full orthoptic assessment involves several dif-
ferent tests to assess the patient’s vision, binocu-
larity, ocular movements, and symptoms.
Orthoptic Assessment Visual Acuity (Vision)
Cover Test
Orthoptists are specialists in ocular motility. Their Binocular Functions
input into the management of orbital fractures is Ocular Movements
valuable both pre- and postoperatively. The extra- Hess Charts
ocular muscles are particularly susceptible to Measuring Globe Position
78 9 Orbital Fractures
Surgical Repair
Timing
When orbital fractures coexist with other frac-
tures of the midface (zygoma, nasoethmoid, fron- Timing of surgery is dependent on a number of
tal bone), these must be repaired first. Safe orbital factors. Immediate exploration and repair is
dissection and successful repair of orbital defects rarely required. However indications for urgent
are dependent on key landmarks and a correctly repair include significant entrapment of the mus-
positioned infraorbital rim to support the implant. cles. In most “blowouts” it is the orbital fat that is
This will not be possible if the peripheral bones trapped. However, muscle entrapment (which can
are significantly displaced. be seen on coronal CT views) can potentially
result in ischaemic injury to the muscle and sub-
sequent fibrosis. Inappropriately severe pain is
Indications for Repair considered by some to be a sign of this.
Otherwise, most blowout fractures can be left
Surgical repair is a controversial area of practice. safely for up to 7–10 days if necessary. Swelling
While some fractures clearly require repair and should be allowed to resolve to enable further
others clearly do not, there remains a “grey area” assessment. Repairing a blowout fracture in the
in which the need for surgery is largely a matter of presence of significant swelling may put the
opinion. This is partly due to the problem in defin- patient at risk of developing orbital compartment
ing what is “clinically significant” enophthalmos, syndrome postoperatively.
Blowout Fractures 79
Transcutaneous Approaches
Figs. 9.10, 9.11, 9.12 and 9.13 An incision approximately midway between the subciliary and subtarsal levels has
been sited in a suitable skin crease. Using fine tenotomy scissors, the muscle fibres of the underlying orbicularis muscle
fibres are gently separated, proceeding towards the infraorbital margin. Splitting of the muscle fibres exposes the
underlying orbital septum and periosteum. These are then incised with a scalpel along the entire length of the infraor-
bital rim, a few millimetres below the crest. Using a sharp periosteal elevator, the periosteum is then gently lifted
80 9 Orbital Fractures
Figs. 9.14, 9.15, 9.16 and 9.17 The retroseptal approach is one of the simplest and most direct approaches to
make. A low conjunctival incision can be placed deep in the fornix, just above the orbital rim. A second incision
is then made through the remaining tissues and periosteum. The periosteum is then elevated along the length of
the rim
Blowout Fractures 81
Preseptal Approach
Figs. 9.18, 9.19, 9.20 and 9.21 In the preseptal approach, an incision is made through the conjunctiva, below
the tarsus. A plane of dissection is then developed between the more superficial orbicularis muscle and the
orbital septum. Once the orbital rim is exposed, the periosteum is incised and elevated
Repair of Defects
many donor sites have been described in the Medial Orbital Fractures
literature. Alternatively, allogenic materials can
be used. Today there are many different materials Fractures of the medial orbital wall can occur in iso-
available, including titanium sheets, mesh, poly- lation, or as a medial extension of orbital floor
mers and newer resorbable materials. Titanium is defects. For a number of reasons, these are a difficult
currently a popular choice. group of fractures to repair—access is somewhat
Whatever the choice of material, the aim is to limited and deep dissection along the medial orbital
accurately restore the shape (and hence the wall comes into very close contact with the orbital
volume) of the orbit. This can be difficult, espe- apex. Significant bleeding can also occur due to the
cially when two or more walls are fractured. proximity of the ethmoidal vessels.
Although it may be possible to completely
reduce the orbital contents and span the entire
defect, the complex curvatures of the orbital
walls means that a flat sheet of material may not
necessarily restore the shape. The commonest
site where this problem occurs is at the postero-
medial bulge.
Fig. 9.23 Repair using titanium has the advantage of Figs. 9.24 and 9.25 Extensive medial wall blowout frac-
allowing critical evaluation on postoperative scans ture with gross herniation of tissues
Medial Orbital Fractures 83
Figs. 9.26 and 9.27 A zig-zag design minimises unsightly scarring. Through this incision, the underlying periosteum
is incised and subperiosteal dissection along the medial wall undertaken. The obvious limitation here is the attachment
of the medial canthus, which restricts access and prevents passage of any sizeable implant. The canthus should not be
detached. These incisions generally heal well with acceptable scarring
84 9 Orbital Fractures
More recently the transcaruncular approach has Transnasal endoscopic-assisted repair is a very useful
gained increasing popularity. In a sense, this can technique that greatly assists the repair of medial wall
be thought of as a medial transconjunctival fractures. By combining transorbital access with an
approach, with elements similar to the retroseptal endoscopic-assisted transnasal approach, precise
dissection. reconstruction of large orbital defects is possible.
Figs. 9.28, 9.29, 9.30, 9.31, 9.32 and 9.33 Following incision of the conjunctiva, blunt dissection (using tenot-
omy scissors) is progressed behind the medial canthal attachment onto the posterior lacrimal crest on the medial
wall. It is here that the periosteum is then incised and elevated, leaving the medial canthus and lacrimal sac
undisturbed. Through this incision the periosteum can be widely elevated exposing most of the medial wall as
far back as the orbital apex
Medial Orbital Fractures 85
Figs. 9.34, 9.35, 9.36 and 9.37 In the case shown, the orbit has been accessed through a midtarsal incision.
The infraorbital nerve should be clearly identified as it exits through its foramen. Prior to osteotomy, a relocation
plate or plates can be prepared. This technique should ensure that the fragment is returned precisely to its correct
position
86 9 Orbital Fractures
The Forced Duction Test craniofacial fractures. Either way, these occur
following high-energy injuries and as such may
The forced duction test is an important part of the also be associated with injuries globe.
assessment of orbital fractures. It is often under- Orbital apex fractures commonly occur fol-
taken to determine if there is any soft tissue lowing high-energy blunt trauma or penetrating
entrapment resulting in restricted movements of orbital trauma. Radiographically, three types of
the globe. The test can be carried out in the clinic injury have been described:
under local anaesthetic if there is uncertainty 1. Linear without displacement of fragments
regarding mechanical or neurological pathology. 2. Comminuted with fracture displacement
It should also be carried out following orbital 3. Apex avulsion with an intact optic foramen.
floor exploration and repair, before the patient is
woken up, to ensure there is no residual entrap-
ment of soft tissues. Clinical Syndromes
The globe is gently rotated away from the sus- Superior orbital fissure syndrome (also known
pected site of entrapment. Any residual tethering as Rochon-Duvigneaud’s syndrome)
of the soft tissues will result in an abrupt cessa- Injury to the cranial nerves passing through
tion of rotation. This needs to be carried out care- the fissure results in diplopia, paralysis of
fully to avoid damage to the eye or conjunctiva. the extraocular muscles, proptosis, and
The anaesthetist should also be warned before- ptosis
hand, as pulling on the globe can result in pro- If blindness or visual impairment is also
found bradycardia. present with these features, it is called
an orbital apex syndrome.
Nasal bone
Frontal process
of maxilla
Upper lateral
cartilage
Adult nasal
framework
Diagnosis of nasal fractures is usually clinical, This appears as a dark red swelling on the septum
not radiological, although radiographs may be and results in partial nasal obstruction, usually
required if other injuries are suspected. In high- within the first 24–72 h. Untreated it can become
energy injuries, it is important to ensure that frac- infected, leading to septal abscess (with a risk of
tures have not extended into the orbits, ethmoid intracranial extensions). Alternatively the septum
region or skull base. can undergo avascular necrosis with loss of carti-
lage and septal perforation. Large perforations
can result in collapse of the entire septum, result-
ing in a “saddle nose” deformity. Incision and
Assessment of Nasal Fractures drainage can be performed under local
Consider the following: anaesthesia.
Mechanism of injury: are significant inju-
ries likely?
Has the bleeding stopped? (especially if the Management of Nasal Fractures
patient is supine)
CSF leaks (cribriform plate fractures): ask Indications for treatment can be considered as
patient to lean forward and refrain from functional or aesthetic. Generally speaking,
sniffing. Watch for watery discharge manipulation is carried out approximately
Visual acuity: high-energy fractures can 5–10 days after the injury when the swelling has
extend along the medial orbital walls to resolved. Open reduction and internal fixation
the apex (ORIF) through an overlying laceration or suit-
Septal haematoma: needs urgent evacuation ably sited skin incision may also be indicated.
Septal deviation resulting in reduced air The decision to ORIF nasal injuries depends on a
entry number of factors. If there is an open wound
Lacerations (both externally and intrana- (externally or internally), then repair should be
sally) +/− exposed bone/cartilage expedited and carried out sooner if possible.
Nasal deviation: ideally compare to recent
pictures of patient.
Is the intercanthal distance normal? MUA Nose
Could this be an old injury?
Manipulation of the nasal bones is a common yet
often underappreciated procedure, which if per-
formed poorly can result in residual deformity.
The Septum Failure to straighten the septum will inevitably
result in some relapse, even if the nose appears
The nasal septum is a key component in both the straight at the end of the procedure. This is due
assessment and repair of nasal injuries. Not only to cartilage’s inherent elasticity. Digital manipu-
does it provide nasal projection but it also defines lation of the nose may be possible in “low-
the midline position of the nose. If the septum is energy” fractures where the nose has been
significantly deformed this can also result in displaced “en bloc,” with buckling or bowing of
nasal obstruction. the septum.
92 10 Nasal Fractures
Manipulation Using
Instrumentation
Fig. 10.3 Manipulation of nasal bones with Fig. 10.4 Ashes forceps
Walsham forceps
Open Reduction and Internal Fixation of Nasal Bones 93
Once the bones have been manipulated, the Open Reduction and Internal
septum must be carefully assessed for align- Fixation of Nasal Bones
ment and any tears in the mucosa. If deviated,
the septum can be straightened using Ashes In appropriately selected cases this is a very use-
forceps. ful technique that has a low complication rate. As
such it should be considered whenever there is an
overlying laceration. When attempting to repair
complex nasal injuries, a number of important
Comminuted Nasal Fractures steps must be followed, although the sequence
may vary slightly. Due to varying degrees of com-
With higher energy injuries both the nasal plexity between cases, each of these steps may
bones and the septum may be significantly need to be addressed to a greater or lesser extent.
comminuted. These are very difficult fractures
to manage with a high incidence of residual
deformity. Anatomical reduction of a commi- Key Steps When Repairing Complex Nasal
nuted septum is virtually impossible and when Injuries
coupled with comminuted nasal bones, some Make sure you know your nasal anatomy
degree of residual deformity and collapse is Septum: realign and reestablish projection
almost inevitable. For this reason some author- Nasal mucosa: watertight closure
ities advocate placing a bone graft along the Nasal bones: repair key fractures and those
dorsum of the nose at the time of primary that are large enough to support plates
repair. Following manipulation of comminuted and screws. Maintain as much soft tis-
fractures, plastic splints may be used to sup- sue attachment as possible
port the septum during the healing period. Cartilages: repair obvious tears and reattach
However, the evidence for these benefits is upper lateral cartilages to the nasal bones.
mostly anecdotal and some surgeons do not Consider grafts if cartilage has been lost
like to use splints at all. Splints may increase External wounds: use these for access.
the risk of infection and if poorly fitting can Meticulous debridement, haemostasis,
ulcerate through the nasal skin and mucosa. and a layered closure
Nasal packs may also be required for haemo- Consider the need for primary bone graft-
stasis, or to support the septum, splints or nasal ing (a “dorsal strut”)
bones. These come in various form, impreg- Consider the need for septal splints and
nated with either Vaseline or BIPP (bismuth external support
iodoform paraffin paste).
94 10 Nasal Fractures
Nasomaxillary Fractures
Classification
Figs. 11.6 and 11.7 In this case the canthal tendon was relatively easily identified but was completely detached
from bone. Following repair of the underlying fractures, reattachment was achieved by first securing a 1.5-mm
titanium plate along the medial orbital wall, placing one of its holes over the predetermined site of canthal reat-
tachment. The canthus was then secured to this hole using a wire ligature
Canthal Access Through Local Under the right circumstances, the cantile-
Incisions vered technique can work well, but it does
require sufficiently rigid plates. Otherwise the
With isolated injuries to the medial canthal region, plate simply deforms, allowing the canthus to
sufficient access may be possible through local drift laterally. It also requires structurally solid
incisions. The decision to repair canthal injuries surrounding bones to which the plate can be
through local incisions depends on a number of secured.
factors. A number of local incisions are possible.
Figs. 11.8 and 11.9 Unilateral NOE and nasomaxillary fractures following a localised injury (struck by a
cricket ball). The canthus had drifted laterally. Access was planned through a zigzag nasal incision and by exten-
sion of the small medial subtarsal wound. The nasomaxillary fracture was reduced and plated. The canthus was
attached to small fragments of bone only. This was reattached to a cantilevered plate secured to the nasomaxil-
lary bones
100 11 Nasoethmoid (Naso-Orbital-Ethmoid): NOE Fractures
Figs. 11.11 and 11.12 In the case shown a coronal flap was required to expose the patient’s extensive facial
injuries. The medial canthus had been completely detached from bone with only a few small fragments to help
relocate its position precisely. Fixation of the canthus was therefore undertaken using a “canthal hook.” This is
essentially a wire suture with a small “anchor-like” barb on the end. Following adjustment of the canthus the
wire was then secured to frontal bone using a small screw
Injuries to the Lacrymal Drainage System 101
Lacrimal gland
Naso lacrimal
duct draining into
lateral nasal wall
The term “Panfacial fracture” implies that frac- tissues of the face—notably the facial muscles,
tures will be widespread throughout the facial eyes, dentition and upper airway. Together with
skeleton. As such, they will probably follow high- the overlying soft tissue envelope, they define the
energy impacts (possibly with associated commi- shape of the face.
nution), or they may follow multiple impacts The thicker bones can be grouped into four
(commonly seen in assaults). Fractures to the transverse and four (paired) vertical “buttresses”
teeth, mandible, maxilla, zygoma, nasoethmoid and it is the precision in the repair of these bones
(NOE) region, orbits and frontal sinus are there- that is especially important in facial trauma. The
fore all possible. When the skull base is seriously transverse buttresses define facial projection and
disrupted or there are coexisting neurosurgical width, while the vertical buttress define facial
injuries, the term “craniofacial” fracture is used. height. Consequently when planning surgery it
It may be helpful to think of these fractures as may be useful to consider the fracture pattern in
multiple and complex fractures involving two or terms of these buttresses. In most cases these will
more regions of the face, or as high-energy frac- be the sites of internal fixation. Comminution in
tures simultaneously involving the upper, middle one or more buttresses is particularly important
and lower face. Other definitions exist. These as bone grafting may be required.
represent significant and often severe injuries to
both the bones and soft tissues.
Specific Considerations in Panfacial
Fractures
Applied Anatomy
An important element in management is accurate
The facial skeleton is composed of a number of assessment and identification of all “key” frac-
“strut-like” bones, which form the boundaries of tures and any significant associated injuries.
the orbits, sinuses and nasal cavity. The thicker Although all fractures should be identified, some
bones are connected together by thinner “sheets” are more important than others, particularly when
of bone, to which the soft tissues of the face are planning manipulation and internal fixation. This
attached. Overall, this arrangement provides sup- includes sites such as the skull base, nasoethmoid
port and protection to the different functional region, orbital apex, palate and condyles.
All patients should ideally have a CT scan Common incisions Structures exposed
with facility to display fine cut, axial, coronal and Preauricular, Mandibular condyle, ascending
sagittal views. Three-dimensional imaging is also retromandibular ramus, lower border posterior
mandible
very useful, but caution is advised in relying
Existing lacerations Direct access
solely on this. Dental models are helpful in
assessing maxillary and mandibular arch frac-
tures. They are also useful in the fabrication of One of the main principles in panfacial fracture
acrylic splints and custom arch bars. repair is to accurately restore the facial but-
Further considerations include how soon sur- tresses in all three dimensions. However, the
gery should be undertaken. “Early” intervention precise order in which the fractures are repaired
(approximately 7–10 days) has been reported to has been much debated. Currently there is still
result in improved functional and cosmetic out- no consensus as to which is the best sequence.
comes. Unfortunately longer delays may be “Bottom to top”, “top to bottom”, and “outside
unavoidable. In situations where treatment is to inside” are just a few sequences that have
delayed for more than 3 weeks, repair becomes been proposed. In practice these sequences do
technically much more difficult. not always follow a simple order and there is
some degree of overlap between them. Due to
the varying permutations of fracture patterns
Surgical Access and Sequencing possible in panfacial fractures, no single
sequence will reliably work every time. Don’t
Adequate exposure of panfacial fractures is be afraid to be flexible in your sequencing. Try
essential for precise repair. If required, the entire to think logically about what the next step
face can be accessed through a few carefully should be and its effects on the whole, rather
placed incisions. Those which are commonly than blindly following a formula.
used are summarised.
Bottom to Top
Access to the Facial Skeleton
The first step is to reestablish the “maxilloman-
Common incisions Structures exposed dibular unit” (MMU). Once the correct width of
Coronal Frontal, nasoethmoidal, upper one dental arch is restored, this can be used as a
three quarters of orbit, nasal
root, zygomatic arch, skull reference for the other. Following restoration of
Upper lid Frontozygomatic suture, lateral the MMU, the sequence then continues, starting
orbital rim and wall at the calvarium and proceeding in a caudal direc-
Transconjunctival/ Inferior orbital rim, orbital tion. This is followed by further repair of the
subciliary/subtarsal/floor, lower medial/lateral “outer facial frame” beginning at the root of the
mid lid orbital walls
zygomatic arch and advancing to the lateral
Maxillary Maxilla, midfacial buttress
gingivobuccal sulcus
orbital walls and infraorbital rims. The final cor-
Mandibular vestibular Mandibular symphysis to rection is at maxillary buttress, nasal complex/
sigmoid notch septum and orbits.
Bottom to Top 105
Fractures Sustained
• Bilateral mandibular fractures
• Left zygoma
• Comminuted left nasomaxillary and nasal
fractures with unilateral naso-orbitoethmoid
(NOE) fracture
• Anterior wall frontal sinus
Access Via
• Coronal flap
• Left transconjunctival incision
• Upper left buccal sulcus
• Intraoral mandibular
The coronal (or bicoronal) flap is a commonly insertion for the occipitofrontalis muscle. Its
used flap which provides excellent exposure of attachment extends posteriorly, from the supe-
the upper half of the face and skull. A number rior nuchal line round the superior temporal
of minor modifications have been described, line, while more laterally it continues with the
but the basic concepts and flap design remain temporal fascia. This is a key area when raising
the same. By raising the flap in the subgaleal a coronal flap.
plane, taking with it at least the outermost layer
of the temporalis fascia at the sides, (several
layers have been described), the upper branches Anatomical Landmarks of the
of the facial nerve should remain protected and Facial Nerve
undamaged.
In essence this is a scalping-type procedure in The facial nerve exits the stylomastoid foramen
which the front half of the scalp is pulled for- and passes into the parotid gland. Here it lies in a
wards, pivoting just in front of the ears. fibrous plane separating the deep and superficial
Considerable variation in the placement of the lobes of the gland. The nerve then divides into
scalp incision is possible, allowing a more poste- two major divisions: an upper “temporal-facial”
rior position in patients with receding hairlines. and lower “cervicofacial” branch. These then
divide further into its five terminal branches.
The uppermost of the five terminal branches
Applied Anatomy (temporal or frontal branch) passes upwards and
forwards into the forehead. It is this branch which
Functionally the scalp can be considered as two is mostly at risk when raising a coronal flap,
layers: although traction palsy of the entire nerve can
• A superficial layer from the skin to the galea occur if the flap is retracted too aggressively. To
aponeurotica, and avoid injury to the upper branch, two landmarks
• A deep layer consisting of areolar tissue and are useful:
pericranium. 1. A point 1 cm in front of the tragus (or alterna-
The aponeurosis is the key component to tively the upper attachment of the pinna)
understanding these flaps. It is a thin, tendi- 2. A point 1 cm lateral and 2 cm above the lateral
nous, sheet-like structure which provides the end of the eyebrow
Surgical Technique
Figs. 13.2, 13.3 and 13.4 In the case shown, temporalis dissection is started first. A skin incision is com-
menced at the lower attachment of the pinna, passing upwards towards the upper attachment. From there it
passes into the lateral hair-bearing portion of scalp, gently curving backwards and upwards. The incision is
deepened down to the zygomatic arch and the attachment of the temporalis fascia along its upper border
Figs. 13.6 and 13.7 The scalp is then carefully elevated off the underlying periosteum. The plane of dissection
here is the loose connective tissue between the galea and periosteum. This part of the dissection is quite easy and
rapid. Some surgeons may inject saline into this plane prior to incision to facilitate elevation, a technique known
as “hydrostatic dissection” or “hydrodissection”
Figs. 13.8 and 13.9 The temporalis fascia is then incised and its outermost layer bought forwards and down,
along with the scalp. This part of the dissection requires careful attention. Placement of the incision in the tem-
poralis fascia can vary but corresponds to the landmarks previously described for the upper branch of the facial
nerve. The entire scalp is reflected forwards, over the patient’s face until a horizontal line approximately 2 cm
above the super orbital ridges is reached
Surgical Technique 119
Figs. 13.11 and 13.12 Depending upon the exposure required, periosteal elevation along the zygomatic arch
may also be necessary. In extensive fractures the entire zygomatic arch, lateral orbital rim, and much of the
zygomatic prominence can be exposed. Bringing the coronal flap forwards can expose the nasoethmoid region,
most of the nasal bones and the upper two thirds of the medial and lateral orbital walls, as well as the orbital roof
Soft Tissue Injuries
14
For a more detailed review of this topic see Atlas of Operative Maxillofacial
Trauma Surgery by M Perry and S Holmes.
The term “soft tissues” is a nonspecific term, The very rich blood supply of the head and
which can be interpreted to mean different things. neck helps to defend this site against infection
In the context of this manual, “soft tissues” refers and promote healing. Despite high intraoral
to all the non-bony structures, including fat, mus- bacterial counts, infected wounds within the
cle, nerves or vessels. An important element in mouth are surprisingly uncommon. Saliva and
management is to remember it is more than just exudates from around the gingiva contain anti-
the skin. This is important not only in the repair bodies and various growth factors, which facili-
of soft tissue injuries, but also in the planning of tate rapid wound healing and prevent infection.
follow-up and aftercare in all trauma. However, skin does not have these protective
Any wound that breaches the dermis will mechanisms and infection may arise not only
result in a permanent scar. How extensive this from external sources, but also from naturally
scarring is depends on a number of factors related occurring commensal organisms. Penetrating
to the trauma itself, the patient’s biology, treat- injuries need particular attention. Bacteria can
ment received and aftercare. Optimal manage- be driven deep into the tissues and are then
ment is therefore essential. Thorough wound difficult to eradicate.
toilet, judicious debridement and meticulous tis-
sue handling are all required to achieve the best
possible aesthetic and functional outcomes. Even
if the skin has remained intact following an
impact, subsequent neglect or mismanagement of
the injured site can still result in significant defor-
mity or disability.
Classification of Wounds
Classification of Wounds
Clean
Sharp incision
Low energy trauma
Uncontaminated
Less than 6 h old
Compromised
Ragged edge
Fig. 14.2 Delayed presentation of subperichondrial hae-
High-energy trauma matoma. The ear had been stitched, but no pressure dress-
Crushed tissue ing applied. There has been further bleeding and
Tissue loss infection
Burns
Contaminated
More than 12 h old Initial Assessment
and Management
Figs. 14.3 and 14.4 Some wounds can be quite deceptive. What initially appears as a trivial wound is in fact
very extensive
Figs. 14.8 and 14.9 This patient initially attended thinking she had been stung by a wasp. X-ray confirmation of an
air gun pellet
Debridement and Trimming of Wounds 125
Figs. 14.11 and 14.12 A contaminated nasal abrasion following a fall. This has been carefully cleaned and dressed.
Appearances at 2 months
Figs. 14.13 and 14.14 Trimming of irregular skin edges can make wound closure easier
Figs. 14.16, 14.17, 14.18 and 14.19 Avoid pinching the skin edges with toothed forceps; rather, use a skin
hook, or one side of the forceps as a hook to hold the wound edge steady whilst you place the suture. Note the
curve of the needle and use a smooth wrist rotation to glide it smoothly through the tissues. Pull the suture mate-
rial through gently. Sutures can be placed in an interrupted or continuous fashion: it may be argued that inter-
rupted sutures give a superior aesthetic result, but continuous intradermal sutures can give a very acceptable
aesthetic outcome when placed carefully. Do not tie the knots too tight
Injuries to Specialised Tissues 129
talking, eating, facial expression etc. Prolonged use On occasion, gross swelling may also preclude
of adhesive strips helps reduce stretching of the primary closure. In the case shown, excessive pro-
immature scar. Subcuticular sutures may be kept in ptosis (from oedema) precluded closure of the
place for longer, as scarring is less likely. Deep wounds following repair of the fractures. Closure
prolene sutures provide long term support was not possible until a further 3 days had passed.
Craniofacial fractures by their very nature involve necessarily propagate along them. The skull is
the combined efforts of both facial surgeons and thickest over the vertex. It is thinnest in the tem-
neurosurgeons. The dura forms a convenient ana- poral region and where it forms the roof of the
tomical barrier to neurosurgical involvement— orbits and nose. Internally the skull is divided
evidence of trauma to the dura itself, or any of the into the anterior, middle and posterior cranial
structures deeper to it, mandates a neurosurgical fossae.
opinion. All other facial injuries out with the dura
do not, although consultation may still be advis-
able in some cases. Investigation and manage- The Frontal Sinuses
ment of associated intracranial injuries always
takes priority over facial injuries. These form a cavity within the frontal bone, con-
sisting of anterior and posterior walls or “tables”
and a floor. These are highly variable in size and
Applied Anatomy shape and are rarely symmetrical. A midline sep-
tum separates the two but this is also highly vari-
The Skull able and usually deviates to one side. The average
sinus is approximately 6–8 mL in volume. Mucus
The skull consists of the calvarium and the facial drains into the middle meatus of the nose via the
skeleton. The calvarium consists principally of frontonasal ducts (also called frontal sinus drain-
eight bones. These behave as a single functional age pathways [FSDP]). One of the main concerns
unit. Unlike some bones of the face, the suture in the management of frontal sinus and nasoeth-
lines are very strong and fractures do not moid fractures is the patency of these ducts.
a b
Frontal sinus fractures can be classified into The internal carotid and vertebral arteries supply the
fractures of the anterior table, posterior table, or brain with blood. The internal carotid artery enters
fractures of both. The “floor” of the sinus is the skull via the carotid foramen in the middle cra-
sometimes included with the posterior wall. nial fossa (MCF) and divides into the anterior and
middle cerebral arteries. Due to the high energy
required, fractures in the MCF should raise concerns
The Meninges about vascular injury. The two vertebral arteries
unite to form the basilar artery, which then divides
Between the skull and brain are three membranous into the two posterior cerebral arteries. These supply
layers, the meninges. The outer membrane, the the cerebrum, cerebellum, and brainstem.
dura mater, is a tough fibrous membrane which
lines the inner surface of the bone. The dura also
forms several internal partitions: the falx cerebrum Ventricular System
(which separates the two cerebral hemispheres),
the tentorium cerebelli (which separates the middle The two lateral ventricles produce around
and posterior cranial fossae) and the falx cerebelli 450 mL of CSF daily. Only 20 mL of CSF is in
Understanding Head Injuries 133
the ventricles; the rest is circulated throughout glucose). In a sense, the whole aim of the rapid
the subarachnoid space. CSF is replaced approxi- primary survey in Advanced Trauma Life Support
mately three times every day. Following circula- (ATLS®) is to maintain the delivery of oxygen-
tion it is passively resorbed through the arachnoid ated blood (preferably the patient’s own blood) to
villi over the cortical surface. Blood in the CSF the brain. Crudely speaking this process may fail
(from either traumatic or spontaneous subarach- due to a number of mechanisms.
noid haemorrhage) can block this process, result-
ing in raised ICP.
Reaching the “Final Common Pathway”
in Secondary Brain Injury
Hypoxia
Understanding Head Injuries Obstructed airway (FB, facial injuries)
Inadequate ventilation (reduced respiratory
rate, pneumothorax, haemothorax, etc.)
The aim of head injury management is to Not giving oxygen
prevent secondary brain injury from occur- Hypovolaemia
ring as a result of various mechanisms. Internal/external blood loss (including
Maintaining the optimal physiological facial injuries)
environment maximises the brain’s recov- Hypotension
ery from the primary injury. Cardiac causes, drugs, spinal injuries
Raised intracranial pressure (ICP) and
reduced brain perfusion
EDH, SDH, Cerebral contusions/haema-
“Primary” brain injury occurs at the time of toma, cerebral oedema
impact. As such there is nothing we can do about Depressed fractures
this. Prevention is the only way to reduce this.
“Secondary” brain injury occurs after the initial
event and is due to a variety of mechanisms. One
way or another, these all result in either hypoxia
or inadequate cerebral perfusion. Hypoglycaemia In the very early stages of reduced cerebral
is another important (and preventable) cause of perfusion, there is loss of higher functions,
secondary injury. notably how alert the patient is. This is why
the Glasgow Coma Scale (GCS) is so
important in assessment.
Pathophysiology
The brain is the most sensitive organ in the Any developing intracranial mass will at
body to hypoxia and ischaemia. Therefore, first be compensated for by displacement of
it is essential to maintain an adequate sup- venous blood and CSF. At this stage the intra-
ply of well-oxygenated blood to it, espe- cranial pressure (ICP) will not rise. However,
cially when it has been injured. when this compensatory mechanism reaches
its limit, the ICP will then rapidly rise and the
cerebral perfusion pressure (CPP) quickly fall.
Cushing’s reflex then comes into play, increas-
Whatever the cause, the final common pathway ing the systemic blood pressure to maintain
for secondary brain injury remains the same— cerebral blood flow. The pulse rate conse-
the brain is deprived of oxygen (or sometimes quently falls due to a reflex vagal response.
134 15 Craniofacial Fractures and the Frontal Sinus
Untreated, progressive cerebral ischaemia or otorrhoea, Battle’s sign, panda eyes, scalp
occurs which leads to cerebral infarction and lacerations).
brain death. If this continues untreated, brain
herniation may eventually occur (“coning”).
The Glasgow Coma Scale (GCS)
Investigations
CSF Leaks
Principles of Management
in Craniofacial Trauma
Aesthetic
Structural Fig. 15.7 Errors built into the repair of the frontal bandeau
are conveyed lower down the face as repair progresses
The portion of bone running horizontally across
the forehead from one frontozygomatic suture to in all three dimensions in order for the middle
the other is sometimes referred to as the “frontal and lower face to have solid and anatomically
bandeau.” This region must be repaired accurately precise articulations.
Planning Repair 137
Functional
When sequencing multiple incisions, lower
This refers to the frontal sinus and maintaining its eyelid access and cantholysis must be per-
function and drainage. Failure to do so can have formed first and closed last. If not, it will be dif-
serious consequences. ficult to predictably reattach the lateral canthus.
Displaced
No Yes
Frontonasal duct
involved
No Yes
time-consuming than a direct approach. With more extensive fractures, or if there are
Direct access to the fractures can also been concerns regarding possible CSF leaks, it is prob-
made through suitable forehead skin creases. ably safer to raise a coronal flap.
Although this is a much smaller procedure it
carries the risk of more visible scarring and
injury to the sensory nerves of the forehead.
Due to its restricted access, repair of extensive
fractures through this incision can be difficult.
Careful evaluation of the fracture configura-
tion is therefore necessary. This approach is
best suited for simple localised fractures.
Routine use of bone has now been challenged Posterior table fractures that are displaced more
by the excellent results of titanium. than the width of the bone itself are reported to be
Nevertheless, if donor bone is available it still an indicator for dural tears and CSF leaks. If the
has a valid role to play. frontonasal duct is partially obstructed, mucocele
Like all bone grafts, the success of cranial formation is also a possibility.
grafts is dependent on several things: Management of posterior frontal sinus wall
1. Adequate immobilization: this allows fractures therefore depends on the perceived risks
revascularisation of meningitis. When dural tears are evident, the
2. Adequate healthy soft tissue coverage: also options are therefore to:
required for revascularisation 1. Either proceed to a craniotomy with formal
3. Minimal contamination: to prevent infection. repair of the dura and cranialise the sinus or
2. To adopt a “wait and see” approach—most
CSF leaks will spontaneously cease if left
Reconstruction of Anterior Wall Plus alone.
Sinus Obliteration Craniotomy and dural repair is a major sur-
gical procedure, with potentially significant
This may be required following fracture of the complications. Some surgeons therefore argue
anterior table with involvement of the frontona- that in the absence of an active CSF leak, this
sal duct. A variety of materials have been is not justified on the basis that the patient
reported to successfully obliterate the sinus, might get meningitis; i.e., this is a major “pro-
including abdominal fat, autogenous bone, and phylactive” procedure. However, others argue
pericranium. that since the risks are life long, the cumulative
risk becomes high and can justify surgery. This
remains an area of ongoing controversy.
When obstruction of the frontonasal duct is
present, there are three treatment options:
restore the anatomy, cranialise the sinus, or
obliterate it. Attempts at repairing the fronto-
nasal duct using stents have been reported.
However, stenosis is a problem in approxi-
mately one third of patients. The principle
behind cranialisation is to remove the posterior
sinus wall, remove all mucus secreting epithe-
lium from the remaining cavity, plug the fron-
tonasal ducts, and allow the brain to expand
into the cavity. Obliteration involves removing
Fig. 15.23 The anterior wall has been recon- all of the mucosa from the frontal sinus, filling
structed, and the pericranium inserted via the ante-
the sinus with autogenous material such as fat
rior edge of the repair. The pericranium should
totally obturate the cavity; further fibrin glue may or pericranium, and plugging the frontonasal
also be applied duct with fat, to essentially isolate the frontal
sinus from the nose.
144 15 Craniofacial Fractures and the Frontal Sinus
No Yes
CSF leak
No Yes
Resolution at No resolution
7 days at 7 days
Figs. 15.25 and 15.26 Following craniotomy, hae- The remaining cavity is obturated in a layered fashion.
mostasis, brain retraction, and removal of sinus lining, This includes free pericranium, fibrin glue, free bone
the posterior wall is carefully removed by rongeurs. graft, more fibrin glue and lastly, pedicled pericranium
Posterior Sinus Wall Fractures (Types 2 and 3) 145
Figs. 15.27 and 15.28 The anterior wall is ele- Fig. 15.29 In this case the extent of the vault and
vated. In this case both the posterior sinus wall and anterior skull base fractures totally preclude the
frontonasal ducts were clearly intact following use of an extended local incision. The patient
NOE manipulation. There was therefore no indica- required elevation of the frontal bone plus evacua-
tion to cranialise or obturate the sinus and the ante- tion of haematoma
rior wall was repositioned and plated
Check for Cerebrospinal Fluid Leakage A well-aligned septum is important for nasal pro-
jection and position. A comminuted septum can
In the supine patient, cerebrospinal fluid (CSF) be virtually impossible to anatomically reduce
leakage may not be obvious as fluid may not nec- and a degree of overlap of its fragments is inevi-
essarily leak out the nose. Gently clean and table. Septal splints may help.
Have the Soft Tissues Been Resuspended? 151
Globe Protection
Tarsorrhaphy (Temporary)
Bone Grafts
Fig. 17.5 Deep circumflex iliac artery (DCIA) flap. This Fig. 17.6 Corticocancellous bone is a nonvascularised
is a vascularised “free-flap,” which includes the curvature graft which can preserve the crest and muscle attach-
of the iliac crest. Potentially a very large graft, but requires ments. These blocks are much smaller but are usually
detachment of a number of large muscles. Most com- adequate in trauma
monly used following ablative surgery
Figs. 17.7, 17.8, 17.9 and 17.10 Harvest right Iliac crest (arrow) bone graft
Alternative Donor Sites and calvarial bone follow the same principles as
for iliac bone—the periphery of the graft is
Alternative donor sites for free bone include the defined and an osteotome is used to separate the
chin, ascending mandibular ramus, rib and cal- cortical bone from the underlying cancellous
varial bone. The techniques for harvesting genial bone.
Costochondral Grafts 157
Genial Graft
Costochondral Grafts
A of defects, 81–82
Adhesive eyepatches, 153 indications for, 78
Adult nasal boney and cartilaginous surgical, 78, 83
framework, 90 retroseptal approach, 80
Advanced trauma life support (ATLS), 2–3 timing, 78
Aesthetic craniofacial trauma transcaruncular approach, 84
management, 136 transconjunctival approaches, 80
Airway considerations, in anaesthesia transcutaneous approaches, 79, 83
open (surgical) tracheostomy, 17–18 Bone grafts, 154
percutaneous tracheostomy, 16 Buttress plate, ZMC fracture, 70
submental intubation, 14–16
Alloplastic repair, of anterior sinus wall, 142
Anatomical reduction, of fractures, 147 C
Anteriorly based pericranial flap, in craniofacial Calvarial graft, 157
fractures, 138 Campbell’s lines, 64
Anterior sinus wall Caroticocavernous fistula, 136
fractures, 136, 141 Cartilage grafts, 157
reconstruction of, 143 Cerebral blood supply, 132
repair of Cheek fractures. See Zygomaticomaxillary
alloplastic, 142 complex (ZMC) fractures
autogenous, 143 Closed reduction technique
coronal flap, 141, 142 Gillies lift procedure, 67–68
endoscopic techniques, 141 malar hook technique, 68
midline cutaneous approach, 142 vs. open reduction, 66
Aponeurosis, 115 Coffin-lid approach, 155
Atrophic edentulous mandible fractures, 54 Computed tomography (CT)
Auricular hematomas, 122 condylar fractures, 49
Autogenous repair, of anterior sinus wall, 143 head injuries
Avulsed tooth, 35–36 cerebrospinal fluid leaks, 135
indications for, 135
vascular complications, 135–136
B middle third fractures, of facial skeleton, 58
Bicoronal flaps. See Coronal flaps ZMC fractures, 64, 65
Blowout fractures Conchal cartilage (pinna), 159
clinical assessment, 76–77 Condylar fractures
endoscopic-assisted repair, 84 bilateral, 49
forced duction test, 86 comminuted and complex, 52–53
infraorbital access, 79 CT evaluation of, 49
midtarsal approach, 79 endoscopic assisted repair, 52
orbital fractures extended approach, 51–52
management of, 78 fracture-dislocation, 49
medial, 82 palpable neck, 50
orbitotomy, 85 surgical repair, 49
orthoptic assessment, 77, 78 surgical vs. nonsurgical management, 48
preseptal approach, 81 transparotid approach, 50
repair unilateral, 48
Middle third fractures, of facial skeleton (cont.) patient comparison with preinjury pictures, 151
soft tissue swelling, on airway, 4 well-aligned septum for, 150
split palates, 57, 60 occlusion/midlines and mouth opening, 151
surgical repair, 58 ocular divergence, 149
upper access, 60–61 orbital floor plate orientation, 149
Midface degloving incision, 59 postoperative hooks/arch bar requirement, 151
Midtarsal approach, for blowout fractures, 79 proptosis, 150
pupillary levels, 149
soft tissue resuspension, 151
N spehnozygomatic suture alignment, 148, 149
Nasal fractures transverse facial width, 148
Ashes forceps, 92, 93 zygomatic arch alignment, 148
clinical assessment of, 91 Open globe injury, 11–12
comminuted fractures, 93 Open reduction and internal fixation (ORIF)
digital manipulation, 91, 92 of nasal bones, 93, 94
management of, 91 of ZMC fractures, 68–69
manipulation under anaesthesia, 89 Open reduction vs. closed reduction technique, 66
nasal septum, 91 Orbital apex fractures, 86–87
open reduction and internal fixation, 91, 93, 94 Orbital cellulitis, 78
patterns of, 89 Orbital compartment syndrome, 10–11
plaster of paris splint, 92 Orbital fractures
septal assessment and management, 89 blowout fractures (see Blowout fractures)
septal haematoma, 91 description, 75–76
Walsham forceps, 92 management of, 78
Nasal packing, using urinary catheter, 8 medial, 82
Nasoethmoid fractures, 95. See also Naso-orbital- Orbital roof repair, for craniofacial fractures, 139
ethmoid-frontal (NOE) fractures Orbitotomy, 85
Nasomaxillary fractures, 94
Naso-orbital-ethmoid-frontal (NOE) fractures
access through P
local incisions, 99–100 Palatal repair, 60
overlying lacerations, 98 Panfacial fractures, 4
anatomy, 95–96 anatomy, 103
canthal fixation bottom to top sequence, 104–106
to bone, 100 case studies, 109–113
using Mitek suture, 101 considerations, 103–104
clinical features of, 96–97 exposure of, 104
closed vs. open treatment, 97–98 outer to inner facial frame, 106, 108
dural tears and cerebrospinal fluid leaks, 96 repair principle, 104
lacerated canaliculus, stenting of, 102 surgical access, 104
lacrimal drainage, 96 top to bottom sequence, 106, 107
lacrimal injuries, management options in, 102 vertical and transverse buttress, 103
lacrymal drainage system, anatomy of, 101 Parotid injuries, 129–130
Markowitz classification of, 97 Percutaneous tracheostomy, 16
medial canthus, 96 Posterior frontal sinus wall fractures
precise canthal repositioning in, 98, 99 anterior table fenestration, 145
treatment planning for, 98 complex defects, with associated soft
Nose, anatomy of, 90 tissue trauma, 145
cranialisation of, 144
management of, 143
O Postoperative period
On-table repair assessment advice and instructions, 161
anatomical reduction, of fractures, 147 gentle blowing, of nose, 162
bone grafts, 151 nasal hygiene, 162
cerebrospinal fluid leakage, 150 oral hygiene, 162
cheek projection, 148 wound hygiene, 162
enophthalmos, 150 antibiotics, 163
intercanthal distance and symmetry, 150 elastic intermaxillary fixation, 163
intermaxillary fixation, 151 facial physiotherapy and rehabilitation, 163–164
nasal projection follow-up, 161, 164
Index 169