General Trauma Principles

• 5  criteria predictive of facial fracture: GCS <14, malocclusion, step offs, periorbital swelling/contusion, tooth absence
• In massive nasal/oral hemorrhage –> intubate –> anterior/posterior nasal packing

Soft Tissue Injuries: 

• Scalp: 
• Layers: From superficial to deep – The skin, connective tissue layer, galea, loose areolar plane, pericranium.  
• Avulsions of scalp: typically in the loose areolar plane.
• When suturing the scalp back together the galea is the strength layer

• Injury to the Medial Eye – Canalicular or nasolacrimal duct injury 
• Diagnosis of nasolacrimal duct injury postoperative 
• Jones test: (first step):
• I: evaluates lacrimal outflow under normal physiologic conditions. Fluorescein dye is instilled in conjunctival cornice dye should be  recovered in 5 minutes by asking patient to blow their nose –> if no dye perform jones 2
• II: residual fluorescein flushed out from conjunctival sac–> asks patient to expel drainage from pharynx –> no dye means complete obstruction

• Treatment 
• Occluded punctum: nasolacrimal duct dilation or stent placement
• Conjunctivodacryocystorhunistomy (CDCR) – performed in cases of flaccid canaliculi with paralysis of the lacrimal pump mechanism and when the site of obstruction in proximal 
• Dacryocystorhunostomy (DCR) – performed in cases of distal obstruction

• Mid cheek laceration: 
• Injury to Stetson’s duct
• Treatment – cannulate, can close over stent. Manage with superficial parotidectomy for chronic fistulas 
• Complications: Sialocele should be managed conservatively (pressure dressing, limited PO intake, aspiration, antisialogogues) –> most resolve 2-3 weeks

Frontal Sinus Injuries: 

• Development of the Frontal Sinus 
• Absent at birth 
• Appears in radiographs near age 7 
• Fully developed by age 15 

• Regional Anatomy: 
• Drainage of the frontal sinus via nasofrontal ducts. 

• Fontal Sinus Fractures Associated Injuries:
• Frontal sinus fracture carries 45-65% risk of intracranial injury like TBI

• Frontal sinus fracture Management: 
• Isolated Anterior Table Fractures: 
• Nondisplaced: observation 
• Displaced: 
• Nasofrontal Duct Not Involved: reduction and fixation for aesthetic reasons 
• Nasofrontal Duct Involved: reduction and fixation with obliteration of the frontal sinus mucosa to prevent a mucocele 
• Obliteration Procedure: (1) removal of all the mucosal tissue (2) perform obliteration of the space with a pericranial flap, cancellous bone, fat or synthetic bone cement. 
• Posterior Table Involvement (generally this means that both the anterior and posterior table are involved) 
• Nondisplaced: 
• No CSF Leak: observation
• CSF Leak: observation for 7 days with abx. If no resolution, plan for Dural repair with cranialization
• Displaced Posterior Table (regardless of CSF leak given that the likelihood of a displaced posterior table is high) 
• Nasofrontal duct involvement: reduction and stabilization of the anterior table with cranialization vs. obliteration of the frontal sinus 
• If the nasofrontal duct is not involved you can consider just reduction and stabilization of the anterior table (although generally the nasofrontal duct is involved) 
• Cranialization: removal of posterior table, closure of the dura, nasofrontal tract, and obliteration of sinus mucosa allowing the brain to swell into the frontal sinus 
• Complications: 
• Mucocele: occurs in the frontonasal duct is blocked and all mucous is not removed. This can form a sterile fluid filled cyst that can become infected. Annual CT required for all FS fractures
• Mucopyrocele is infected mucocele 

Orbital Injuries: 

• Anatomy: 
• Seven bones comprise the orbit: ethmoid, frontal, lacrimal, maxilla, palatine, and greater and lesser wings of the sphenoid.
• Most commonly injured part of the orbit is the medial wall of the orbit 

• Orbital Floor: 
• Indications for Emergent Repair: 
• Entrapment of the extraocular muscles: Most commonly entrapped muscle is inferior rectus. More commonly occurs in the pediatric population who are more likely to create a trapdoor effect with orbital floor defects. Can present with n/v. If operative repair is delayed it can result in permanent visual deficits  
• Retrobulbar hematoma: Defined as bleeding posterior to the septum which requires emergent lateral canthotomy for repair to prevent optic nerve injury due to pressure on the nerve 
• Absolute indications for repair: 
• entrapment of inferior rectus with trapdoor deformity (emergent)
• entrapment with vagal symptoms (emergent)
• >50% of the floor (urgent)
• Enophthalmos 
• Defined as posterior displacement of globe most commonly caused by increase in bony orbital volume, disruption of orbital ligaments can also cause (make sure they are intact)
• > 2mm of enophthalmos as measured from the anterior orbit to the lateral rim is an indication for surgery– this may not be evident initially due to swelling. Clinically evident enophthalmos presents after 5% increase in volume of the orbit. (urgent)
• Persistent diplopia – Diplopia is common and should generally be observed as this should resolve with time (10-14 days if there is no entrapment)
• Treatment of Orbital Floor Fractures: 
• Approaches 
• transconjunctival (preseptal vs. postseptal) 
• benefits: no external scar, can be extended medially (trancuruncular incision) or laterally (lateral canthotomy) 
• subciliary 
• Description: just below the lash line 
• Overall benefit: well-hidden scar 
• Overall disadvantage: potential for ectropion 
• Two approaches – 
• skin only flap — above the orbicularis oculi to the infraorbital rim. lots of risk for ectropion and skin necrosis 
• skin-muscle flap — into the orbicularis oculi muscle, but make sure to dissect below the pretarsal portion to prevent loss of lid support. Can be stepped vs. nonstepped 
• subtarsal (midlid) 
• Description: incision through the lower lid, through the orbicularis and then down to the rim in the preseptal plane 
• benefit: okay for older patients with excess lower lid skin  
• disadvantage: potential for scar visibility, potential for ectropion
• rim incision 
• benefit: best exposure 
• disadvantage: poor cosmesis 
• Post-Injury/Post-operative Complications:
• Posttraumatic carotid-cavernous fistula 
• What is it? – abnormal fistula between the internal carotid and cavernous sinus after a basilar skull fracture 
• Signs – pulsatile proptosis, ocular and orbital erythema 
• Diagnosis – cerebral angiogram 
• Treatment – embo  
• Traumatic Neuropathy: 
• Optic nerve: Marcus Gunn pupil 
• Signs: abnormal pupillary dilation when light is shown into the injured eye. Description: If the right optic nerve is injured anterior to the optic chiasm – light shone in the left eye will lead to consensual constriction of the pupils. When light is shown into the right eye there is relative dilation of both eyes. 
• Causes: Can also be caused by shear force injuries of the optic nerve (most common in the trauma setting) and due to central retinal artery occlusion 
• Ectropion: 
• Definition: the lower eyelid scars in an outward position leading the cornea to be exposed and prone to irritation 
• Treatment: 
• Initial: Ectropion: massage 
• Delayed: if persist more than 6 months –> operative fixation. There are multiple options for repair including: horizontal shortening of lower lid, lateral canthoplasty, release of scar tissue and application of frost suture, nasal septal cartilage grafting to support posterior lamella
• Other Eye Injuries: 
• Hyphema: urgent consult to ophthamology; blood in anterior chamber of eye –> can lead to glaucoma. Signs include blindness, blurred vision, eye pain. 

Nasal Bone Injuries: 

• Acute treatment: 
• Drain septal hematomas immediately to prevent necrosis of the septal cartilage 
• Subacute Treatment:
• If there is marked edema wait for closed reduction (3-5 days) and splint nasal pyramid
• Delayed Therapy: 
• Needs to perform osteotomies to reset the nasal bone injury. This should be delayed in acute fractures — nasal collapse may result

NOE Injuries: 

• Definition: fracture of the confluence of the nasal bones, maxilla and frontal orbital bones 

• Bones involved: Five fractures must exist: nasal, inferior orbital rim, ethmoid, nasomaxillary buttress, maxillary frontal process

• Physical Exam
• Telecanthus – >35mm is suggestive of a NOE fracture 
• depressed nasal bridge or upturned tip due to lack of nasal bone support 
• epiphora 
• Diagnosis: CT scan

• Goals of Repair: 
• Rigid fixation of the nasal pyramid 
• Restoration of nasal height and length 
• Restoration of tip projection 
• Septal reduction and reconstruction 
• Lateral nasal wall augmentation 

• Classification System: 
• Markowitz and Manson: this is in regards to the fracture pattern and the medial canthal tendon 
• Type I: single central fragment with minimal displacement and no disruption of medial canthus
• Type II: comminution of the central fragment with attachment of the medial canthal tendon to the large bony fragment: 
• Management I and II: consider nasal dorsum support, plate fx (no need for medial canthal reconstruction). Bony intercanthal distance should be 16-23mm

• Type III: comminution including avulsion of the medial canthus from the large bony segment 
• Management: reconstruct medial orbital wall, bone graft to nasal dorsum; transnasal wiring of medial canthus (overcorrect)

*Medial Canthal Tendon –  consists of three limbs: 1) a prominent anterior limb that inserts medially on the anterior lacrimal crest, 2) a thinner posterior limb that attaches to the posterior lacrimal crest, and 3) a vertical limb of fascia that inserts on the medial orbital rim inferior to the nasal frontal suture

• Postoperative Complications: 
• Epiphora: Observe lacrimal system 90% will see improvement. 

ZMC/Zygomatic Arch 

• Anatomy
• Facial buttresses:
• Vertical: nasomaxillary, zygomaticomaxillary, pterygomaxillary, condyle, posterior mandibular ramus
• Horizontal: frontal, zygomatic, maxillary, mandibular buttresses -mandibular arch

 

• Isolated Zygomatic Arch:
• Nondisplaced: observe
• Displaced: 
• Gilles Approach: dissect down through the deep temporal fascia to the temporals muscle — then pass the elevator bluntly to the arch
• Keen Approach: intraoral approach to the zygomatic arch 
• Reduction Tips: For displaced fractures of zygoma –> use lateral orbital rim (greater wing of sphenoid) as guide (least likely to be comminuted) 

• ZMC: 
• Anatomy: Buttresses zygomaticofontal, zygomaticomaxillary, zygomaticotemporal, zygomaticosphenoidal 
• Pearls of Reduction and Fixation: 
• Use lateral orbital wall as set point for reduction (sphenoid)
• Stable fixation with ZF, ZM and inferior orbital rim
• Enophthalmos associated with inadequate reduction of ZM suture most frequently
• ZMC fractures without good reduction typically have concomitant NOE fractures that must be reduced first
• Larger than 2cm defect in orbital floor after reduction of ZMC necessitates repair
• 8 weeks out from ZMC fracture would require lefort 1 osteotomy and MMF to address malocclusion

LeFort Fractures: 

• Definition: pan facial fractures
• Panfacial fractures have 10% risk of concomitant cervical spine injury;
• Classification: all true LeFort fractures involve the pterygoid plates 
• LeFort I: maxillary sinus fracture involving medial and lateral buttresses
• LeFort II: NOE fractures (nasal bones, ethmoid, lacrimal), orbital floor and infraorbital rim, zygomaticomaxillary buttresses
• LeFort III: NOE, orbital floor, zygomaticosphenoid articulation, lateral orbital wall, zygomaticofrontal buttresses and zygomatic arch 

• Principles of Fixation: 
• (1) In patients with panfacial fractures (maxillary and mandibular) –> reduce and fix mandible first to establish posterior height prior to ORIF of maxillary segments
• (2) establish pre-traumatic maxillomadibular occlusion to prevent bite issues postoperatively  

Other Craniofacial / Maxillofacial Topics: 
Teeth

• Tooth anatomy:
• Visible part is crown, Dentin protects pulp, inner is root and consists of outer cementum, inner dentum and pulp
• Presentations of Tooth Injuries: 
• Sensitivity to cold/pain is due to exposed dentin (can become infected) –> cap 
• Injury to pulp requires removing tooth
• Fracture to alveolar bone requires arch wiring
• Periapical cyst: most common odontogenic cyst- nonviable tooth becomes infected, necrosis of pulp, radiolucency on xray
• Dentigerous cyst: around the top unerupted tooth

 Cranioplasty

• Cranioplasty: coverage large calvaria defects often times following decompressive craniectomy
• Materials Used: 
• Hydroxyapetite contraindicated in radiated fields, not recommended in pediatric population, can use up to 25cm, wait 1 year, frontal area has more complications
• Methylmethacrylate has high compression strength; exothermic, low cost, does not ingrowth, more susceptible tin infection, can be prefabricated with planning (difficult)
• PEEK: (polyetheretherketone) infection is the most common complication
• Other skull fracture: Skull fractures with dural lacerations in children –> can become growing skull laceration GSF, 

Miscellaneous Trauma Information: 
Massive Transfusion Protocol: transfusion of FFP, PRBC at 1:1, discontinuing crystalloid
Treatment of tracheostomy scar includes scar excision and reapproximating of the strap muscles (staernohyoid and sternothyroid)