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Facial and orbital injuries
HEAD AND NECK
(e.g. co-amoxiclav) should be started to prevent toxic shock syndrome. Nasal packing is often insufficient to control vessels bleeding from the posterior nasal cavity. Such bleeds can be difficult to treat and may require balloon insertion or a posterior pack.
Facial and orbital injuries Niall Kirkpatrick
Endoscopic electrocautery The examination of the nasal cavity is performed with a Hopkins rod rigid endoscope (0o or 30o angle). Suction removes clots and locates the bleeding point. Bipolar cautery is then used to seal the vessel. A device with an integrated suction tip improves the field of view and increases the efficiency of cautery. The patient should be observed for two hours and can be discharged if there is no rebleeding.
Neurosurgeons and plastic, oral and maxillofacial, ENT, ophthalmic surgeons share a common interest in craniomaxillofacial trauma and management is best served by a multidisciplinary team. Historically, the surgical management of facial and orbital injuries has been characterized by delayed surgery, small, poorly sited incisions, external and wire fixation of fractures, and late management of the soft tissues. This often resulted in poor cosmetic appearance and functional outcomes. Modern surgical management is based on the principles of craniofacial surgery i.e. early one-stage repair, exposure of all fracture fragments by correctly sited cosmetic incisions, precise internal fixation, immediate bone grafting and definitive management of soft tissues.
Surgery Bleeding which fails to stop requires surgical intervention. Diathermy: nasal instrumentation and the subsequent localization of a bleeding point is much easier under general anaesthesia. Bipolar diathermy is safer (particularly when operating close to the orbit) than monopolar diathermy because of the risk of inadvertent thermal damage associated with monopolar diathermy. Septal surgery: most haemorrhage occurs from the septum. Hence, the raising of a mucoperichondral flap during septal surgery will decrease blood flow to the mucosa. Septal surgery is also used to correct a deviated septum or septal spur, which may be the underlying cause of the epistaxis.
History There is evidence from mummies that fractures and dislocations of the jaw were treated in ancient Egypt. Hippocrates described the use of circumdental wires and external bandages for immobilization of fractured jaws. Interdental fixation to splint the fractured mandible against the intact maxilla was recorded by William of Saliceto in 1276. In 1888, Schede used a solid steel plate held by four screws for fixation of a mandible. In 1901, René Le Fort described fractures of the middle one-third of the facial skeleton. External fixation using a halo frame was first used in 1943. The origins of modern craniomaxillofacial plating systems date from the 1960s, and the last decade has seen increasing interest in the use of resorbable plating systems.
Arterial ligation: there are three main types. External carotid artery ligation is a non-specific method of decreasing blood flow to the nose. Studies have shown a long-term failure rate of 45%. This is because of collateral circulation, which can cause continued bleeding despite unilateral arterial ligation. Ligation of the external carotid artery is generally considered a ‘last resort’. However, its relatively straightforward approach and its rapid effect is useful in controlling profound haemorrhage. Maxillary artery ligation is more specific than an external carotid artery ligation and is effective in 87% of cases. A modified Caldwell–Luc procedure is used. Complications include devitalized gums and teeth, sinusitis and problematic intraoperative bleeding. Sphenopalatine artery ligation is the most specific arterial ligation procedure. It is performed under direct rigid endoscopy and the vessel is normally clipped or coagulated using bipolar diathermy. The success rate is better than other forms of arterial ligation, probably because it is an end artery with little collateral flow.
Aetiology Craniomaxillofacial trauma in the adult population in the UK is due to: • interpersonal violence (52%) • road traffic accidents (16%) • sports injuries (19%) • falls (11%) • industrial accidents (2%). Patients may present with isolated facial trauma or severe multisystem injuries. There is a rising incidence of craniomaxillofacial trauma due to interpersonal violence in most ‘developed’ countries. There has, however, been a dramatic reduction in trauma associated with road traffic accidents over the past 20 years in the UK, despite increasing usage of cars. This decrease (about 30%) has been attributed to a number of measures, including:
Other management options include angiographic embolization and the use of cryoprecipitate fibrin glue.
Follow-up Patients who require admission should be reviewed in clinic with a repeat full blood count. Anyone with severe epistaxis should have a formal examination of the nasal cavity to exclude a neoplastic lesion. Patients with high blood pressure on admission need referral to their GP. Anticoagulation may also need to be reviewed.
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Niall Kirkpatrick k is Consultant Plastic and Craniofacial Surgeon in the Multidisciplinary Craniofacial Unit at Chelsea and Westminster Hospital and the Head and Neck Unit at Charing Cross Hospital, London, UK.
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• • • • • • •
sinuses (especially if the patient blows his nose). However, also consider serious injury to the lungs or trachea as a cause.
drink-driving legislation in the 1970s seat-belt legislation in 1983 crumple zones collapsible steering wheels anti-lock braking airbags laminated windscreens.
Eyes Retrobulbar haemorrhage is an ocular emergency, prompting urgent consultation with the ophthalmology team. The signs of retrobulbar haemorrhage are: • severe pain in the affected eye • progressive loss of vision (loss of colour vision is the most sensitive early indicator) • fixed and dilated pupil • proptosis • ptosis • subconjunctival haemorrhage • periorbital oedema. Treatmentt – urgent lateral cantholysis in the A and E department, as well as the use of mannitol i.v. (0.5–2g/kg infused over 30–60 minutes), acetazolamide i.v. (500 mg), and dexamethazone i.v. (4 mg per kg bolus and 2 mg per kg 6 hourly for 24 hours) in order to relieve the intraocular pressure is needed. Formal exploration of the orbit in the operating theatre (with evacuation of the haemorrhage) is an urgent priority.
Assessment Valuable information on the likely severity and extent of the injury (using injury patterns, the direction of injury, type of impacting object, speed and acceleration/deceleration forces involved) must be obtained from the patient or witnesses. The initial assessment and resuscitation of patients with facial trauma follows the Advanced Trauma Life SupportTM (ATLSTM) principles. In all fractures of the facial skeleton, consider possible fractures of the cranial base, cervical spine (5% of patients with facial fractures will have injury of the cervical spine) and larynx. The airway may be compromised by posteriorly displaced fractures of the maxilla and mandible, as well as by inhalation of teeth, dental restorations or fractured dentures. Urgent intubation of the airway must be considered in these circumstances. Severe haemorrhage from the face and scalp is commonly evident, and can usually be controlled with appropriate pressure dressings. Bleeding from the maxillary artery territory can usually be controlled in the Accident and Emergency (A and E) department by nasal balloons in the post-nasal space or other forms of posterior nasal packs, as well as by mouth props.
Fractures of the middle one-third of the face: all patients should have formal ocular assessment by the ophthalmology team. Sixtythree percent of cases will have minor or transient ocular injury, 16% will have moderately severe ocular injury and 12% will have severe ocular injury. The eyelids should be assessed for lacerations, oedema and ecchymosis. Bilateral periorbital ecchymosis, limited by the borders of the orbital septae (‘racoon eyes’) suggests a fracture of the floor of the anterior cranial fossa. The globe and conjunctiva should be examined for lacerations and penetrating injuries (particularly from glass fragments which may be difficult to see). Subconjunctival haemorrhage usually indicates a fracture of one or more of the orbital walls. The orbital margins should be palpated for obvious loss of smooth bone contour. Tenderness along the lateral orbital margin at the level of the zygomaticofrontal suture suggests fractures of the zygomaticorbito-maxillary complex. Formal assessment of visual acuity, pupillary level, hypo-globus, enophthalmos, proptosis, ocular movements and diplopia (including Hess chart), light reflexes and intraocular injury are mandatory. Hypoglobus, enophthalmos, and restriction of ocular motility with diplopia, indicate a significant fracture of the orbital floor or walls. Superior orbital fissure syndromee can follow severe impacts to the lateral wall of the orbit. Approximation of the edges of the superior orbital fissure compresses the neurovascular structures, leading to: • complete ophthalmoplegia and ptosis (III, IV, VI and nerve to levator palpebrae superioris) • loss of direct and consensual light reflexes • dilation of the pupil and loss of accommodation and corneal reflexes • altered sensation in the forehead to the vertex (frontal branch of V). Orbital apex syndrome is an extension of superior orbital fissure syndrome, and includes compression of the optic nerve passing through the optic foramen. It is indicated by loss of the
Examination of the craniomaxillofacial region A systematic examination of craniomaxillofacial injuries must include the areas discussed below. Scalp and skull vault Examine the scalp for lacerations; careful parting of the hair is required because lacerations can be easily missed. Palpate the underlying skull vault, noting any crepitus and large ‘boggy’ haematomas which might indicate underlying skull fracture. Soft tissues of the face Inspect lacerations, especially those that overlie branches of the facial nerve, the parotid gland and duct and important branches of the trigeminal nerve. Inspect lacerations that disrupt the medial and lateral canthal apparatus, the lacrimal system, the eyelid margins, the lip vermilion–cutaneous border, as well as the pinna. Injuries involving these structures will require careful exploration and repair, including microsurgical repair of nerves and the parotid duct. Sensation must be tested in all significant branches of the trigeminal nerve i.e. the supraorbital, supratrochlear, infraorbital, zygomaticofacial, zygomaticotemporal and mental nerves. Obvious facial deformity and asymmetry should be noted. In particular, measure the intercanthal distance (normally 30–34 mm). Widening of the intercanthal distance (telecanthus) may indicate fracture of the naso-orbito-ethmoidal complex. ‘Surgical emphysema’ (as evidenced by crepitus in the soft tissues of the face and neck) suggests fractures into the paranasal
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Mandible Altered sensation in the distribution of the mental nerve in the lower lip is frequently seen in mandible fractures. Palpation of the ramus and lower border of the mandible will indicate bony steps in the normal anatomy. Crepitus and tenderness of the temporomandibular joint may be felt by placing the index fingers just in front of the tragus of the ear, and within the external auditory meatus, whilst asking the patient to open and close the mouth. If there are any doubts about possible fractures of the mandible, gentle bimanual compression at the angles of the mandible will usually elicit pain in the presence of a fracture.
consensual light reflex in the unaffected eye. Controversy exists as to whether urgent operative decompression brings more rapid or certain recovery than conservative management. Children – great care must be taken when examining a child with orbital injury because greenstick fractures of the orbital floor can lead to entrapment of the inferior rectus muscle, leading to painful restriction in upward gaze and diplopia. This is an orbital emergency, requiring urgent release in the operating theatre in order to prevent muscle necrosis. Ears Inspection of the post-auricular region overlying the mastoid bone may demonstrate ecchymosis (Battle’s sign), indicating fracture of the middle cranial fossa. Look for lacerations of the pinna. Microsurgical replantation of traumatic total pinnectomy is occasionally possible, but partial amputations of the ear should not be resutured in the A and E department: surgery by an experienced plastic surgeon is needed. The external auditory meatus should be examined with an otoscope for bleeding, cerebrospinal fluid otorrhea, haemotympanum or a ruptured tympanic membrane. Blows to the mandible can result in the mandibular condyle being driven through the anteroinferior wall of the external auditory meatus. Such signs should be evaluated by the ENT team. Nose Fractures of the nasal bones are common, but oedema can make assessment difficult. Palpation of the nasal bones may elicit underlying fracture. Severe injury of the naso-orbito-ethmoid complex causes a ‘saddle-shaped’ depression of the nasal bridge. Cerebrospinal fluid rhinorrhoea indicates fractures of the floor of the anterior cranial fossa. Intranasal examination is mandatory to exclude fracture/dislocations of the nasal septum and septal haematoma. Failure to observe and drain septal haematoma may lead to septal necrosis, resulting in loss of septal support, and late ‘saddle nose’ deformity.
Intraoral examination Ascertain from the patient whether, when he bites his teeth together, the occlusion feels normal or abnormal. Observe obvious steps in the occlusal planes, as well as lacerations of the mucosa and tongue. Significant haemorrhage may occur from tongue lacerations involving the lingual artery, and lower buccal sulcus lacerations involving the facial artery. Sub-lingual ecchymosis is pathognomonic of fractures of the lingual cortical plate of the mandible. Check for missing teeth, tooth fragments, dental restorations or fragments of dentures. These may be inhaled during a period of impaired consciousness. In such cases, a chest radiograph is mandatory to exclude such inhaled foreign bodies (see ‘Foreign bodies in the ear, nose and throat’ page 182). Occasionally, fragments of teeth may be present within the soft tissues of the lips and cheeks; radiographs of soft tissue can demonstrate this. Fractures of the jaws in the tooth-bearing portion are compound into the mouth via the periodontal ligaments. Percussion of teeth with a metal instrument gives a characteristic ‘cracked teacup’ sound if fractures of the tooth are present. Avulsed adult teeth should be re-implanted and stabilized as soon as possible (if the general condition permits). Advice should be sought from a dental, oral and maxillofacial surgeon. The majority of minor dental injuries will require referral to the patient’s dental surgeon for restoration.
Middle one-third of the face ‘Lengthening’ of the middle one-third of the face is due to downward and backward displacement of the middle one-third of the facial skeleton, and leads to ‘gagging’ of the posterior dental occlusion and an anterior open bite. Assessment from above and behind the head demonstrates retro-displacement and rotation of the zygoma. The maxilla should be palpated for crepitus or any movement, particularly relative to the frontonasal and frontomaxillary sutures. Intraoral palpation should be extended along the anterior maxilla and zygomaticomaxillary buttresses, and externally along the zygoma and zygomatic arch, feeling for evident bony deformity and tenderness. Altered sensation in the distribution of the infraorbital nerve, periorbital ecchymosis, subconjunctival haemorrhage and ecchymosis in the upper buccal sulcus are characteristic signs of fractures of the zygomatic-orbito-maxillary complex. Depressed fractures of the zygomatic arch may lead to an inability to move the mandible across to the affected side, due to ‘blocking’ of the mandibular coronoid process by the depressed arch (coronoid impingement).
Radiological assessment The assessment of craniomaxillofacial injuries is primarily clinical, and generally there is no urgency for radiographic assessment. Poor-quality radiographs, taken out-of-hours in the A and E department, should be deferred for good-quality imaging in the radiology department. Appropriate radiological investigation should be discussed with the craniomaxillofacial trauma team and the radiology department. Early radiological investigations should exclude injury of the cervical spine and skull fractures. Further assessment should be planned depending on the condition of the patient and the site of the suspected facial fracture. CT T is the first-line imaging method, especially in the assessment of the orbits and middle one-third of the face (Figure 1). If a CT of the brain is performed urgently, and facial fractures are suspected, fine CT cuts (2 cm apart) of the face should be requested at the same time. Radiographs – if a plain radiograph is required for urgent evaluation of the mid-face, a 10–15° occipitomental view is the most useful. Commonly requested plain radiograph views of the face include: • ‘brow up’ lateral projection of the face and skull
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a a CT scan (coronal view) showing typical left zygomaticorbito-maxillary complex fracture (arrows). b CT scan (coronal view) showing the large increase in orbital volume occurring with a ‘blow-out’ fracture of the left posteromedial floor of the orbit (arrow). c Three-dimensional computer reconstruction of the upper and midface in a patient who sustained complex, comminuted pan-facial fractures (see Figure 2).
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• early mobilization of the jaw. It is possible to access the craniofacial skeleton through incisions that produce an excellent cosmetic result in the majority of patients. Common incisions include: • bicoronal incision within the hairline • skin crease incision of the upper eyelid • a variety of incisions of the lower eyelid • intraoral incisions. Preauricular, submental and submandibular incisions are sometimes required and, when well planned and executed, produce good quality scars.
• posteroanterior views of the facial bones • 15° and 30° occipitomental views for assessment of orbital and zygomatic fractures • submentovertex view for fractures of the zygomatic arches and palate • orthopantomogram for assessment of the mandible • reverse Towne’s view (30° posteroanterior view) for the mandible condylar neck • occlusal and periapical films for dento-alveolar fractures.
Management
Craniomaxillofacial plating systems There are a variety of craniomaxillofacial plating systems, and each craniomaxillofacial team must decide on the relative merits. Modern, low-profile plating systems and screws made of titanium are highly biocompatible such that, in the UK and USA, it is common to leave them in situ after fracture healing (except in the growing child). In some parts of Europe, it is usual to remove the screws and plates after fracture healing. Rarely, patients can suffer from cold intolerance of the plates in sub-zero temperatures. There is increasing interest in the use of resorbable plating systems. These do not have the tensile strength, low profile and cost-effectiveness of titanium plates, but they can be used in the growing child and can be tolerated in sub-zero temperatures.
Principles of treatment The timing of treatment depends on the general condition of the patient, and is often delayed for other priorities in patients with multisystem injuries. Other than the urgent priorities of facial trauma discussed above, scrub clean facial lacerations and abrasions contaminated by dirt and small foreign particles within the first 24 hours (in order to avoid permanent tattooing of the skin). Ideally, repair should be performed as soon as: • the patient has been fully assessed clinically and radiographically • a definitive surgical plan has been made • all members of the craniomaxillofacial team have been assembled to repair hard and soft tissues. Optimal treatment of the facial skeleton requires open reduction and internal fixation with: • precise anatomical reduction of fracture fragments • stable internal fixation with appropriate screws and plates
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Treatment of fractures Fractures of the upper one-third of the face: fractures of the frontal bone, anterior cranial fossa floor/orbital roof and naso-ethmoid
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fractures are approached using a bicoronal incision, preserving a pericranial flap for possible use in sealing breaches of the dura. A frontal craniotomy may be required, and careful management of the involved frontal sinus is important to prevent the complications of infection and mucocele formation (Figure 2).
Fractures of the middle one-third of the face: historically, many fractures of the zygomatic-orbito-maxillary complex were inadequately treated by closed reduction techniques such as the Gillies lift (using a temporal incision, an elevator is passed beneath the deep temporal fascia to allow elevation of the zygomatic arch and body of the zygoma), and percutaneous hook elevation of the bone behind the zygomaticomaxillary buttress. Unstable fractures frequently relapsed, leading to poor cosmetic outcomes. Whilst the Gillies lift remains popular in the reduction of isolated fractures of the zygomatic arch (which are usually stable), these techniques should be considered adjunctive to open, precise internal fixation of zygomatic-orbito-maxillary fractures. The positioning of screws and plates is usually dictated by the individual fracture pattern and degree of comminution but, in principle, follows the main buttresses of the middle one-third of the face (Figure 5).
Orbital fractures: previous inadequate management of orbital fractures is responsible for the poor functional and cosmetic outcomes seen in facial fractures. The posteromedial wall of the orbit is convex, and inferiorly displaced fractures lead to a significant increase in intraorbital volume (Figure 1). Inadequate repair of such fractures will lead to disfiguring late enophthalmos. Fractures of the medial orbital walls may include fragments attached to the medial canthal tendon, leading to traumatic telecanthus unless these are adequately repaired (Figure 3). Following the return of herniated orbital contents back into the orbit, the walls or floor must be reconstructed. Materials – alloplastic materials such as titanium meshes and plates, polyethylene sheets and resorbable materials have been advocated. They have a place in the management of orbital fractures, but the author’s preference is for repair with bone grafts, preferably harvested from the cranium (Figure 4).
Nasal fractures: isolated fractures of the nasal bone are best assessed five to seven days later, when the oedema has settled. Radiographs are not necessary for the diagnosis. Simple fractures can be treated by gentle manipulation under local or general anaesthesia. However, failure to recognize and manage displacement
2 Patient seen in Figure 1c. The fractures of the frontal bones and superior orbits have been approached via a bicoronal incision. A bicoronal incision allows good access to the zygomatic arches and midfacial skeleton, permitting precise internal fixation of the fracture. Seen in b left lateral view, c anterior view and d right lateral view.
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The usual sites of placement of osteosynthesis plates along the major buttresses of the midfacial skeleton
3 A bicoronal incision has been used to approach a fracture fragment attached to the left medial canthal tendon. Lateral displacement of this fragment led to telecanthus.
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This allows early rehabilitation. Usually, two plates are required in the anterior mandible to overcome torque in this region; in simple fractures posterior to the mental foramen, usually one plate suffices. The management of fractures of the condylar neck remains controversial and is divided between advocates of closed fracture management techniques and those who favour open reduction and internal fixation.
4 A large fracture of the left orbital floor has been reconstructed with a a cranial bone graft and b via a lower eyelid transconjunctival incision with lateral canthotomy.
Complications The majority of complications for craniomaxillofacial trauma are seen late and are due to a failure to adhere to the principles of treatment discussed in this contribution. Late enophthalmos due to failure to restore intraorbital volume in fractures of the orbital floor is particularly disfiguring, as is retraction of the lower eyelid due to poorly sited (or inadequately resuspended) incisions of the lower eyelid. Failure to accurately reduce and fix the craniomaxillofacial skeleton may lead to incorrect dental occlusion, leading to dental and temperomandibular joint pain, unstable fibrous bony union (rare) and late asymmetry of the face. Postoperative infection is rare in these patients, but infection of screws and plates, requiring their removal, is 5–15%. In early infection before bony union, reverting to older techniques of external frame fixation may be necessary.
of the nasal septum usually leads to late nasal deviation. Nasal bones which are not stable following closed manipulation should be stabilized by percutaneous wire techniques which are removed after one week. Severe fractures of the nasal bone usually require open reduction and internal fixation. Mandibular fractures: it is imperative that the correct occlusion is restored when treating fractures of the mandible. Failure will result in major morbidity to the dentition and temporomandibular joint, resulting in discomfort, pain and poor function. Whilst several weeks of intermaxillary fixation (usually termed maxillary-mandibular fixation) has been successfully used in the past, its role is usually now only intraoperatively, allowing correct alignment of the bony fragments during open reduction and internal fixation.
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FURTHER READING Ward Booth P, Schendel S A, Hausamen J. Maxillofacial surgeryy volume 1. Edinburgh: Churchill Livingstone, 1999.
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(e.g. co-amoxiclav) should be started to prevent toxic shock syndrome. Nasal packing is often insufficient to control vessels bleeding from the posterior nasal cavity. Such bleeds can be difficult to treat and may require balloon insertion or a posterior pack.
Facial and orbital injuries Niall Kirkpatrick
Endoscopic electrocautery The examination of the nasal cavity is performed with a Hopkins rod rigid endoscope (0o or 30o angle). Suction removes clots and locates the bleeding point. Bipolar cautery is then used to seal the vessel. A device with an integrated suction tip improves the field of view and increases the efficiency of cautery. The patient should be observed for two hours and can be discharged if there is no rebleeding.
Neurosurgeons and plastic, oral and maxillofacial, ENT, ophthalmic surgeons share a common interest in craniomaxillofacial trauma and management is best served by a multidisciplinary team. Historically, the surgical management of facial and orbital injuries has been characterized by delayed surgery, small, poorly sited incisions, external and wire fixation of fractures, and late management of the soft tissues. This often resulted in poor cosmetic appearance and functional outcomes. Modern surgical management is based on the principles of craniofacial surgery i.e. early one-stage repair, exposure of all fracture fragments by correctly sited cosmetic incisions, precise internal fixation, immediate bone grafting and definitive management of soft tissues.
Surgery Bleeding which fails to stop requires surgical intervention. Diathermy: nasal instrumentation and the subsequent localization of a bleeding point is much easier under general anaesthesia. Bipolar diathermy is safer (particularly when operating close to the orbit) than monopolar diathermy because of the risk of inadvertent thermal damage associated with monopolar diathermy. Septal surgery: most haemorrhage occurs from the septum. Hence, the raising of a mucoperichondral flap during septal surgery will decrease blood flow to the mucosa. Septal surgery is also used to correct a deviated septum or septal spur, which may be the underlying cause of the epistaxis.
History There is evidence from mummies that fractures and dislocations of the jaw were treated in ancient Egypt. Hippocrates described the use of circumdental wires and external bandages for immobilization of fractured jaws. Interdental fixation to splint the fractured mandible against the intact maxilla was recorded by William of Saliceto in 1276. In 1888, Schede used a solid steel plate held by four screws for fixation of a mandible. In 1901, René Le Fort described fractures of the middle one-third of the facial skeleton. External fixation using a halo frame was first used in 1943. The origins of modern craniomaxillofacial plating systems date from the 1960s, and the last decade has seen increasing interest in the use of resorbable plating systems.
Arterial ligation: there are three main types. External carotid artery ligation is a non-specific method of decreasing blood flow to the nose. Studies have shown a long-term failure rate of 45%. This is because of collateral circulation, which can cause continued bleeding despite unilateral arterial ligation. Ligation of the external carotid artery is generally considered a ‘last resort’. However, its relatively straightforward approach and its rapid effect is useful in controlling profound haemorrhage. Maxillary artery ligation is more specific than an external carotid artery ligation and is effective in 87% of cases. A modified Caldwell–Luc procedure is used. Complications include devitalized gums and teeth, sinusitis and problematic intraoperative bleeding. Sphenopalatine artery ligation is the most specific arterial ligation procedure. It is performed under direct rigid endoscopy and the vessel is normally clipped or coagulated using bipolar diathermy. The success rate is better than other forms of arterial ligation, probably because it is an end artery with little collateral flow.
Aetiology Craniomaxillofacial trauma in the adult population in the UK is due to: • interpersonal violence (52%) • road traffic accidents (16%) • sports injuries (19%) • falls (11%) • industrial accidents (2%). Patients may present with isolated facial trauma or severe multisystem injuries. There is a rising incidence of craniomaxillofacial trauma due to interpersonal violence in most ‘developed’ countries. There has, however, been a dramatic reduction in trauma associated with road traffic accidents over the past 20 years in the UK, despite increasing usage of cars. This decrease (about 30%) has been attributed to a number of measures, including:
Other management options include angiographic embolization and the use of cryoprecipitate fibrin glue.
Follow-up Patients who require admission should be reviewed in clinic with a repeat full blood count. Anyone with severe epistaxis should have a formal examination of the nasal cavity to exclude a neoplastic lesion. Patients with high blood pressure on admission need referral to their GP. Anticoagulation may also need to be reviewed.
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Niall Kirkpatrick k is Consultant Plastic and Craniofacial Surgeon in the Multidisciplinary Craniofacial Unit at Chelsea and Westminster Hospital and the Head and Neck Unit at Charing Cross Hospital, London, UK.
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• • • • • • •
sinuses (especially if the patient blows his nose). However, also consider serious injury to the lungs or trachea as a cause.
drink-driving legislation in the 1970s seat-belt legislation in 1983 crumple zones collapsible steering wheels anti-lock braking airbags laminated windscreens.
Eyes Retrobulbar haemorrhage is an ocular emergency, prompting urgent consultation with the ophthalmology team. The signs of retrobulbar haemorrhage are: • severe pain in the affected eye • progressive loss of vision (loss of colour vision is the most sensitive early indicator) • fixed and dilated pupil • proptosis • ptosis • subconjunctival haemorrhage • periorbital oedema. Treatmentt – urgent lateral cantholysis in the A and E department, as well as the use of mannitol i.v. (0.5–2g/kg infused over 30–60 minutes), acetazolamide i.v. (500 mg), and dexamethazone i.v. (4 mg per kg bolus and 2 mg per kg 6 hourly for 24 hours) in order to relieve the intraocular pressure is needed. Formal exploration of the orbit in the operating theatre (with evacuation of the haemorrhage) is an urgent priority.
Assessment Valuable information on the likely severity and extent of the injury (using injury patterns, the direction of injury, type of impacting object, speed and acceleration/deceleration forces involved) must be obtained from the patient or witnesses. The initial assessment and resuscitation of patients with facial trauma follows the Advanced Trauma Life SupportTM (ATLSTM) principles. In all fractures of the facial skeleton, consider possible fractures of the cranial base, cervical spine (5% of patients with facial fractures will have injury of the cervical spine) and larynx. The airway may be compromised by posteriorly displaced fractures of the maxilla and mandible, as well as by inhalation of teeth, dental restorations or fractured dentures. Urgent intubation of the airway must be considered in these circumstances. Severe haemorrhage from the face and scalp is commonly evident, and can usually be controlled with appropriate pressure dressings. Bleeding from the maxillary artery territory can usually be controlled in the Accident and Emergency (A and E) department by nasal balloons in the post-nasal space or other forms of posterior nasal packs, as well as by mouth props.
Fractures of the middle one-third of the face: all patients should have formal ocular assessment by the ophthalmology team. Sixtythree percent of cases will have minor or transient ocular injury, 16% will have moderately severe ocular injury and 12% will have severe ocular injury. The eyelids should be assessed for lacerations, oedema and ecchymosis. Bilateral periorbital ecchymosis, limited by the borders of the orbital septae (‘racoon eyes’) suggests a fracture of the floor of the anterior cranial fossa. The globe and conjunctiva should be examined for lacerations and penetrating injuries (particularly from glass fragments which may be difficult to see). Subconjunctival haemorrhage usually indicates a fracture of one or more of the orbital walls. The orbital margins should be palpated for obvious loss of smooth bone contour. Tenderness along the lateral orbital margin at the level of the zygomaticofrontal suture suggests fractures of the zygomaticorbito-maxillary complex. Formal assessment of visual acuity, pupillary level, hypo-globus, enophthalmos, proptosis, ocular movements and diplopia (including Hess chart), light reflexes and intraocular injury are mandatory. Hypoglobus, enophthalmos, and restriction of ocular motility with diplopia, indicate a significant fracture of the orbital floor or walls. Superior orbital fissure syndromee can follow severe impacts to the lateral wall of the orbit. Approximation of the edges of the superior orbital fissure compresses the neurovascular structures, leading to: • complete ophthalmoplegia and ptosis (III, IV, VI and nerve to levator palpebrae superioris) • loss of direct and consensual light reflexes • dilation of the pupil and loss of accommodation and corneal reflexes • altered sensation in the forehead to the vertex (frontal branch of V). Orbital apex syndrome is an extension of superior orbital fissure syndrome, and includes compression of the optic nerve passing through the optic foramen. It is indicated by loss of the
Examination of the craniomaxillofacial region A systematic examination of craniomaxillofacial injuries must include the areas discussed below. Scalp and skull vault Examine the scalp for lacerations; careful parting of the hair is required because lacerations can be easily missed. Palpate the underlying skull vault, noting any crepitus and large ‘boggy’ haematomas which might indicate underlying skull fracture. Soft tissues of the face Inspect lacerations, especially those that overlie branches of the facial nerve, the parotid gland and duct and important branches of the trigeminal nerve. Inspect lacerations that disrupt the medial and lateral canthal apparatus, the lacrimal system, the eyelid margins, the lip vermilion–cutaneous border, as well as the pinna. Injuries involving these structures will require careful exploration and repair, including microsurgical repair of nerves and the parotid duct. Sensation must be tested in all significant branches of the trigeminal nerve i.e. the supraorbital, supratrochlear, infraorbital, zygomaticofacial, zygomaticotemporal and mental nerves. Obvious facial deformity and asymmetry should be noted. In particular, measure the intercanthal distance (normally 30–34 mm). Widening of the intercanthal distance (telecanthus) may indicate fracture of the naso-orbito-ethmoidal complex. ‘Surgical emphysema’ (as evidenced by crepitus in the soft tissues of the face and neck) suggests fractures into the paranasal
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Mandible Altered sensation in the distribution of the mental nerve in the lower lip is frequently seen in mandible fractures. Palpation of the ramus and lower border of the mandible will indicate bony steps in the normal anatomy. Crepitus and tenderness of the temporomandibular joint may be felt by placing the index fingers just in front of the tragus of the ear, and within the external auditory meatus, whilst asking the patient to open and close the mouth. If there are any doubts about possible fractures of the mandible, gentle bimanual compression at the angles of the mandible will usually elicit pain in the presence of a fracture.
consensual light reflex in the unaffected eye. Controversy exists as to whether urgent operative decompression brings more rapid or certain recovery than conservative management. Children – great care must be taken when examining a child with orbital injury because greenstick fractures of the orbital floor can lead to entrapment of the inferior rectus muscle, leading to painful restriction in upward gaze and diplopia. This is an orbital emergency, requiring urgent release in the operating theatre in order to prevent muscle necrosis. Ears Inspection of the post-auricular region overlying the mastoid bone may demonstrate ecchymosis (Battle’s sign), indicating fracture of the middle cranial fossa. Look for lacerations of the pinna. Microsurgical replantation of traumatic total pinnectomy is occasionally possible, but partial amputations of the ear should not be resutured in the A and E department: surgery by an experienced plastic surgeon is needed. The external auditory meatus should be examined with an otoscope for bleeding, cerebrospinal fluid otorrhea, haemotympanum or a ruptured tympanic membrane. Blows to the mandible can result in the mandibular condyle being driven through the anteroinferior wall of the external auditory meatus. Such signs should be evaluated by the ENT team. Nose Fractures of the nasal bones are common, but oedema can make assessment difficult. Palpation of the nasal bones may elicit underlying fracture. Severe injury of the naso-orbito-ethmoid complex causes a ‘saddle-shaped’ depression of the nasal bridge. Cerebrospinal fluid rhinorrhoea indicates fractures of the floor of the anterior cranial fossa. Intranasal examination is mandatory to exclude fracture/dislocations of the nasal septum and septal haematoma. Failure to observe and drain septal haematoma may lead to septal necrosis, resulting in loss of septal support, and late ‘saddle nose’ deformity.
Intraoral examination Ascertain from the patient whether, when he bites his teeth together, the occlusion feels normal or abnormal. Observe obvious steps in the occlusal planes, as well as lacerations of the mucosa and tongue. Significant haemorrhage may occur from tongue lacerations involving the lingual artery, and lower buccal sulcus lacerations involving the facial artery. Sub-lingual ecchymosis is pathognomonic of fractures of the lingual cortical plate of the mandible. Check for missing teeth, tooth fragments, dental restorations or fragments of dentures. These may be inhaled during a period of impaired consciousness. In such cases, a chest radiograph is mandatory to exclude such inhaled foreign bodies (see ‘Foreign bodies in the ear, nose and throat’ page 182). Occasionally, fragments of teeth may be present within the soft tissues of the lips and cheeks; radiographs of soft tissue can demonstrate this. Fractures of the jaws in the tooth-bearing portion are compound into the mouth via the periodontal ligaments. Percussion of teeth with a metal instrument gives a characteristic ‘cracked teacup’ sound if fractures of the tooth are present. Avulsed adult teeth should be re-implanted and stabilized as soon as possible (if the general condition permits). Advice should be sought from a dental, oral and maxillofacial surgeon. The majority of minor dental injuries will require referral to the patient’s dental surgeon for restoration.
Middle one-third of the face ‘Lengthening’ of the middle one-third of the face is due to downward and backward displacement of the middle one-third of the facial skeleton, and leads to ‘gagging’ of the posterior dental occlusion and an anterior open bite. Assessment from above and behind the head demonstrates retro-displacement and rotation of the zygoma. The maxilla should be palpated for crepitus or any movement, particularly relative to the frontonasal and frontomaxillary sutures. Intraoral palpation should be extended along the anterior maxilla and zygomaticomaxillary buttresses, and externally along the zygoma and zygomatic arch, feeling for evident bony deformity and tenderness. Altered sensation in the distribution of the infraorbital nerve, periorbital ecchymosis, subconjunctival haemorrhage and ecchymosis in the upper buccal sulcus are characteristic signs of fractures of the zygomatic-orbito-maxillary complex. Depressed fractures of the zygomatic arch may lead to an inability to move the mandible across to the affected side, due to ‘blocking’ of the mandibular coronoid process by the depressed arch (coronoid impingement).
Radiological assessment The assessment of craniomaxillofacial injuries is primarily clinical, and generally there is no urgency for radiographic assessment. Poor-quality radiographs, taken out-of-hours in the A and E department, should be deferred for good-quality imaging in the radiology department. Appropriate radiological investigation should be discussed with the craniomaxillofacial trauma team and the radiology department. Early radiological investigations should exclude injury of the cervical spine and skull fractures. Further assessment should be planned depending on the condition of the patient and the site of the suspected facial fracture. CT T is the first-line imaging method, especially in the assessment of the orbits and middle one-third of the face (Figure 1). If a CT of the brain is performed urgently, and facial fractures are suspected, fine CT cuts (2 cm apart) of the face should be requested at the same time. Radiographs – if a plain radiograph is required for urgent evaluation of the mid-face, a 10–15° occipitomental view is the most useful. Commonly requested plain radiograph views of the face include: • ‘brow up’ lateral projection of the face and skull
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a a CT scan (coronal view) showing typical left zygomaticorbito-maxillary complex fracture (arrows). b CT scan (coronal view) showing the large increase in orbital volume occurring with a ‘blow-out’ fracture of the left posteromedial floor of the orbit (arrow). c Three-dimensional computer reconstruction of the upper and midface in a patient who sustained complex, comminuted pan-facial fractures (see Figure 2).
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• early mobilization of the jaw. It is possible to access the craniofacial skeleton through incisions that produce an excellent cosmetic result in the majority of patients. Common incisions include: • bicoronal incision within the hairline • skin crease incision of the upper eyelid • a variety of incisions of the lower eyelid • intraoral incisions. Preauricular, submental and submandibular incisions are sometimes required and, when well planned and executed, produce good quality scars.
• posteroanterior views of the facial bones • 15° and 30° occipitomental views for assessment of orbital and zygomatic fractures • submentovertex view for fractures of the zygomatic arches and palate • orthopantomogram for assessment of the mandible • reverse Towne’s view (30° posteroanterior view) for the mandible condylar neck • occlusal and periapical films for dento-alveolar fractures.
Management
Craniomaxillofacial plating systems There are a variety of craniomaxillofacial plating systems, and each craniomaxillofacial team must decide on the relative merits. Modern, low-profile plating systems and screws made of titanium are highly biocompatible such that, in the UK and USA, it is common to leave them in situ after fracture healing (except in the growing child). In some parts of Europe, it is usual to remove the screws and plates after fracture healing. Rarely, patients can suffer from cold intolerance of the plates in sub-zero temperatures. There is increasing interest in the use of resorbable plating systems. These do not have the tensile strength, low profile and cost-effectiveness of titanium plates, but they can be used in the growing child and can be tolerated in sub-zero temperatures.
Principles of treatment The timing of treatment depends on the general condition of the patient, and is often delayed for other priorities in patients with multisystem injuries. Other than the urgent priorities of facial trauma discussed above, scrub clean facial lacerations and abrasions contaminated by dirt and small foreign particles within the first 24 hours (in order to avoid permanent tattooing of the skin). Ideally, repair should be performed as soon as: • the patient has been fully assessed clinically and radiographically • a definitive surgical plan has been made • all members of the craniomaxillofacial team have been assembled to repair hard and soft tissues. Optimal treatment of the facial skeleton requires open reduction and internal fixation with: • precise anatomical reduction of fracture fragments • stable internal fixation with appropriate screws and plates
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Treatment of fractures Fractures of the upper one-third of the face: fractures of the frontal bone, anterior cranial fossa floor/orbital roof and naso-ethmoid
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fractures are approached using a bicoronal incision, preserving a pericranial flap for possible use in sealing breaches of the dura. A frontal craniotomy may be required, and careful management of the involved frontal sinus is important to prevent the complications of infection and mucocele formation (Figure 2).
Fractures of the middle one-third of the face: historically, many fractures of the zygomatic-orbito-maxillary complex were inadequately treated by closed reduction techniques such as the Gillies lift (using a temporal incision, an elevator is passed beneath the deep temporal fascia to allow elevation of the zygomatic arch and body of the zygoma), and percutaneous hook elevation of the bone behind the zygomaticomaxillary buttress. Unstable fractures frequently relapsed, leading to poor cosmetic outcomes. Whilst the Gillies lift remains popular in the reduction of isolated fractures of the zygomatic arch (which are usually stable), these techniques should be considered adjunctive to open, precise internal fixation of zygomatic-orbito-maxillary fractures. The positioning of screws and plates is usually dictated by the individual fracture pattern and degree of comminution but, in principle, follows the main buttresses of the middle one-third of the face (Figure 5).
Orbital fractures: previous inadequate management of orbital fractures is responsible for the poor functional and cosmetic outcomes seen in facial fractures. The posteromedial wall of the orbit is convex, and inferiorly displaced fractures lead to a significant increase in intraorbital volume (Figure 1). Inadequate repair of such fractures will lead to disfiguring late enophthalmos. Fractures of the medial orbital walls may include fragments attached to the medial canthal tendon, leading to traumatic telecanthus unless these are adequately repaired (Figure 3). Following the return of herniated orbital contents back into the orbit, the walls or floor must be reconstructed. Materials – alloplastic materials such as titanium meshes and plates, polyethylene sheets and resorbable materials have been advocated. They have a place in the management of orbital fractures, but the author’s preference is for repair with bone grafts, preferably harvested from the cranium (Figure 4).
Nasal fractures: isolated fractures of the nasal bone are best assessed five to seven days later, when the oedema has settled. Radiographs are not necessary for the diagnosis. Simple fractures can be treated by gentle manipulation under local or general anaesthesia. However, failure to recognize and manage displacement
2 Patient seen in Figure 1c. The fractures of the frontal bones and superior orbits have been approached via a bicoronal incision. A bicoronal incision allows good access to the zygomatic arches and midfacial skeleton, permitting precise internal fixation of the fracture. Seen in b left lateral view, c anterior view and d right lateral view.
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The usual sites of placement of osteosynthesis plates along the major buttresses of the midfacial skeleton
3 A bicoronal incision has been used to approach a fracture fragment attached to the left medial canthal tendon. Lateral displacement of this fragment led to telecanthus.
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This allows early rehabilitation. Usually, two plates are required in the anterior mandible to overcome torque in this region; in simple fractures posterior to the mental foramen, usually one plate suffices. The management of fractures of the condylar neck remains controversial and is divided between advocates of closed fracture management techniques and those who favour open reduction and internal fixation.
4 A large fracture of the left orbital floor has been reconstructed with a a cranial bone graft and b via a lower eyelid transconjunctival incision with lateral canthotomy.
Complications The majority of complications for craniomaxillofacial trauma are seen late and are due to a failure to adhere to the principles of treatment discussed in this contribution. Late enophthalmos due to failure to restore intraorbital volume in fractures of the orbital floor is particularly disfiguring, as is retraction of the lower eyelid due to poorly sited (or inadequately resuspended) incisions of the lower eyelid. Failure to accurately reduce and fix the craniomaxillofacial skeleton may lead to incorrect dental occlusion, leading to dental and temperomandibular joint pain, unstable fibrous bony union (rare) and late asymmetry of the face. Postoperative infection is rare in these patients, but infection of screws and plates, requiring their removal, is 5–15%. In early infection before bony union, reverting to older techniques of external frame fixation may be necessary.
of the nasal septum usually leads to late nasal deviation. Nasal bones which are not stable following closed manipulation should be stabilized by percutaneous wire techniques which are removed after one week. Severe fractures of the nasal bone usually require open reduction and internal fixation. Mandibular fractures: it is imperative that the correct occlusion is restored when treating fractures of the mandible. Failure will result in major morbidity to the dentition and temporomandibular joint, resulting in discomfort, pain and poor function. Whilst several weeks of intermaxillary fixation (usually termed maxillary-mandibular fixation) has been successfully used in the past, its role is usually now only intraoperatively, allowing correct alignment of the bony fragments during open reduction and internal fixation.
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FURTHER READING Ward Booth P, Schendel S A, Hausamen J. Maxillofacial surgeryy volume 1. Edinburgh: Churchill Livingstone, 1999.
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