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Multiple fractures of the skull complicated by fractures of the jaws
MULTIPLE FRACTURES
OF THE SKULL COMPLICATED
BY FRACTURES SAMUEL
W.
OF THE JAWS* GARFIN,
M.D.
Junior Visiting Surgeon on Aura1 Service, Boston City HospitaI BOSTON,
M
MASSACHUSETTS
TJLTIPLE
fractures of the skuII complicated by fractures of the upper and Iower jaws are of comparativeIy infrequent occurrence. Even large chnics report reIativeIy few cases. When one searches the Iiterature to obtain aid in the handhng of these comphcated cases, one is struck by the paucity of the reports and more so by the vagueness as to For this reason the their management. author believes that a detaiIed description of this case and its treatment wiI1 be a vaIuabIe contribution on this subject. There were approximateIy 4, IOO patients with fractures of the skuI1 admitted to the Boston City HospitaI in the twenty-five year period from rgr 5 to rg3g incIusive; 727 of these were femaIe. The ages ranged from newborn infants to ninety-two years. AI1 types of fractures were encountered, from the simpIe fracture without any intracrania1 invoIvement to the muItipIe compound type with severe brain comphcations. The sites of the fractures were either the vauIt or the base. Some were compIicated by invoIvement of the nasal sinuses, mastoid, middIe ear and jaws. There were I ,489 deaths resuIting in a mortality rate of 36 per cent. If deaths occurring the first forty-eight hours are excIuded, the mortaIity rate wouId probabIy be nearer 25 per cent. It must aIso be borne in mind that these were not seIected cases but were admissions of severeIy injured patients, many in a dying or comatose condition. Further, they were treated on the genera1 services of the hospita1 in contradistinction to those patients referred to the NeuroIogica1 Service, the statistics of which appear eIsewhere in this paper. There were thirty-four cases complicated
by fracture of the jaws, an incidence of 0.8 per cent. Twenty-eight of these were simpIe fractures, three were compound fractures and in three no mention was made in the record. In this series there were eight deaths, seven occurring within the first forty-eight hours of admission. It is estimated’ that in the United States I 12,000 skuIIs are fractured annuaIIy with 28,000 deaths, a mortaIity of 25 per cent. The greatest mortaIity occurred within the first twenty-four hours. The genera1 mortaIity rate for RamsdeII’s1 series of one hundred consecutive cases was 23.0 per cent. Mock,2 in a statistica study of 8,649 cases, showed a genera1 mortaIity rate of 20.0 per cent. The foIIowing tabIe is a statistica anaIysis of cases of fracture of the skuI1 with crania1 injuries referred to the NeuroIogicaI Department from the Genera1 Services of the hospita1. TABLE
Ratio
Living
of Occurrence
CASES
Dead
laceratml
Total
series.
_.
Tota’
I
______ 63 .a nonoperable cases.. o.9ronc”sslon . 18.2 edema and congestion 25.7 cOnt”SLO*. *3,0.,,,..,.,...,........... 17.3
Mortality Per Cent
~-___
652 II 226 292
106 0
758 II
3 17
229 309
I.3 5.5
123
86
209
41.1
250
1203
20.7
953
‘3.9 0.
19.8
From the tabIe above, it may be seen that the nonoperabIe cases comprise 63.0 per cent. Under the methods of treatment as carried out at the Boston City HospitaI, the immediate mortaIity has remained about 14.0 per cent. This is figured from a11 such cases without regard to the time of their death after
* From the Aura1 Service of the Boston City Hospital, 460
I
NONOPERABLE
Boston,
Massachusetts.
NEW SERIES VOL. LII,
No.
3
Garfin-Fractures
admission to the hospita1. Since these figures are from admissions to speciahzed service (NeuroIogicaI Service of the Boston City Hospital), from a genera1 hospita1 they tend to be higher rather than Iower as cited above. It is impossibIe to standardize the treatment of a11 craniocerebrar injuries, as each individua1 case presents its own requirements. The character of the pathology must, in the Iast analysis serve as a guide for the kind of treatment. The folIowing is an outline of the nonoperative care which I empIoy in the great majority of cases. This is not to impIy that operative indications in this group shouId be ignored. TREATMENT
A summary of the non-operative treatment in craniocerebral injuries and as carried out in this case foIIows: (I) Rest in bed; (2) no morphine; (3) combat shock; (4) combat increased intracrania1 pressure by (a) magnesium suIphate, (b) hypertonic glucose soIution intravenousIy, (c) Iumbar revent dehydration; (6) drainage; (5) p prevent starvation; (7) IocaI treatment, (a) scaIp wounds, compound fractures, (6) discharge from ear and nose (sinuses), (c) other injuries; (I) fracture through the sinuses, (2) fracture of the jaws, etc. Deh.ydration methods are based on the fact that hypertonic soIutions wiI1 withdraw fluids from the body tissues into the blood stream by a process of osmosis. In doing this, the brain is Iikewise depIeted, thus Iessening the increasing edema which h as foIIowed the cerebra1 injury. This method is considered new, yet oId writers on skuI1 fractures advocated rest and purging of the patient as the proper Iine of treatment. Magnesium suIphate 4 ounces, 50 per cent soIution is administered as retention enema and repeated every four to six hours during the first forty-eight hours. GIucose, 50 cc. 50 per cent soIution or I00 cc. 25 per cent solution intravenousIy (steriIe) may be repeated every eight or twelve hours. Glucose mavY be given during c3 the shock~.
of Skull
and Jaws
A merican
Journal
of Surgery
1 61
period. During the first forty-eight hours, Auid intake is restricted; after forty-eight hours fluids may be pushed. The remaining cases are treated as foIIows : Concussion. There being no signs or symptoms of crania1 pathoIogy, except tota unconsciousness, after recovery is compIete and all symptoms have disappeared, treatment other than rest in bed and supportive care is neither indicated nor required. Edema and Congestion. Treatment is directed to shrinking of the brain by dehydration or the remova of the excess of backed-up cerebrospina1 fluid by Iumbar drainage. Dehydration may be carried out by intravenous injection of hypertonic glucose soIution or magnesium suIphate by rectum. With Iumbar puncture, enough cerebrospina1 fluid is removed to reduce an abnormaIIy high pressure to normal Iimits, This shouId be repeated every twenty-four hours unti1 two successive norma pressure measurements have been obtained previous to withdrawa of any fluid. Contusion and Laceration. Treatment is best carried out by a judicious combination of dehydration and Iumbar drainage. Munro3 states that dehydration aIone is inefhcient in these cases in exact ratio to the amount of free bIood in the cerebrospina fluid. This is due to the mechanica bIockage of the arachnoida1 viIIi by the free red bIood ceIIs. Operative decompression as a therapeutic measure is contraindicated. Exploratory trephination, however, can b e properIy empIoyed as a diagnostic measure whenever the patient faiIs to improve after a suitabIe interva1 of properIy executed nonoperative treatment such as outIined above. CerebrospinaI rhinorrhea may, however, prove to be very serious. It is not uncommon in frontal sinus fractures5 and is due invariabIy to a fracture of the cribriform plate” in which a funnel-shaped fragment of the dura and arachnoid has been caught in the fracture line. Munro4 beheves fata meningitis is a certainty unIess the fistuIa
462
A merican Journal of Surgery
Garfin-Fractures
is closed. Packing, irrigation or blowing of the nose should be forbidden. Fractures involving the frontal sinuses
of SkuII and Jaws
JUNE, ,941
hospita1 on the morning of NoveInber 15 in a dazed and semiconscious condition and bled profusely from ;he mouth and nose.
to a nearby
FIG. I. Photograph
of x-ray fiIm showing fractures invoIving the posterior wall of both fronta sinuses, the cribriform pIate, the outer angle and the floor of the left orbit, the Ieft malar, both maxillae and a fracture of the mandibIe at the sgmphisis.
0nIy form a small percentage of our tota cases. Guardigian and Shawan,5 in a series of 2,600 cases of skuII fractures, found an incidence of 5.0 per cent of fronta sinus involvement. The majority of these were asymtomatic and recovered under conservative treatment. Where the posterior waII was invoIved with threatening intracrania1 compIications operation is indicated. CASE
REPORT
A white maIe accountant, age thirty-one, while waIking was struck by a moving auto14, 1937. He Iost conmobiIe on November sciousness immediateIy and was not cIear as to the detaiIs of the accident, but apparentIy he was unconscious for the greater part of the night of November 14 and 14. He was taken
On November 16, he was admitted to the Aural Service of the Boston City HospitaI. The examination was as foIIows: The patient was semiconscious and incoherent. 100.2“~. rectaIIy, 84, 12 B.P. 136/62. T.P.R., The head is described beIow. The right pupil reacted sIuggishIy. ExtraoccuIar movements appeared normaI. The fundus of the right eye (which was the onIy one that could be examined), showed no choking. The ear drums were normal; the abdomen was soft; the bladder was enIarged somewhat; the inguina1 region and genitaIia were negative. Rectal examination showed a scar, presumabry from an ischeorecta1 abscess, to the right of the anus. Prostate was normal. There was some feces in the rectum. The arms and Iegs showed the Iacerations described beIow. PuIses were norand equal. ma1 ; reflexes were hyperactive There was Ieft ankIe c1onu.s but no Bahinski
NEW SERIES VOL. LII. No.
3
Garb-Fractures
or Hoffmann. AbdominaI reflexes obtained. The patient’s past history was
Flc.
were
of Skull and Jaws not
irreIative
2. PIaster mode1 of lower jaw with orthodontia appIiances in pIace. Note the teeth Iigated to externa1 arch wire and the expanding arch on the Iingual surface.
except for an operation for an ischeorectal abscess a year before. There was a ragged Iaceration of the chin and a through-and-through Iaceration of the Iower Iip. The Iower teeth were Ioosened and the Iower right centra1 incisor was missing from an open socket which had a purulent discharge. There was a compound fracture of his Iower jaw through the mucous membrane of the mouth and gums; the fracture line was just to the right of the midIine. The entire jaw was markedIy swoIIen, the upper and Iower lips were Iacerated, and there was considerabIe drooIing of blood and saIiva. The upper jaw was Ioose, dispIaced downward and both centra1 incisors were fractured at their gingiva1 margins. OccIusion was impossibIe. The tongue was markedly swoIIen. The patient was unabIe to swaIIow. There was induration and sweIIing in the right submaxiIIary region extending to the midIine with areas of tenderness over the thyroid cartiIages. The nose was swoIIen, bIeeding and dispIaced toward the right with a depressed fracture of the nasa1 bones and the ascending process of the maxiIIa on the left side. Anterior rhinoscopy showed marked congestion of the entire nasa1 mucosa; the septum was dispIaced toward the right side; the turbinates were engorged and soggy looking, there was considerabIe discharge of mucus, blood and cerebrospina1 fIuid. Posterior rhinoscopy was impossibIe because of the enormous sweIling of tongue and downward dispIacement of the maxiIIa. The soft paIate and uvuIa were mark-
A merican JOUST ofsurgcry
463
There was Iaceration and edIy edematous. abrasion over the upper eye lids with subconjunctival haemorrhage in both eyes. There was
FIG. 3. Plaster model of upper jaw with cast metal pIate and side arms in pIace. considerabIe sweIIing at the outer edge of the Ieft orbita border merging with the maIar bone on that side. X-ray examination reveaIed the folIowing: Left stereo and A.P. of the skuI1 showed muItipIe fractures: (I) through the posterior waI1 of both fronta sinuses; (2) through the cribriform pIate; (3) through the outer angIe of the Ieft orbit; (4) through the floor of the orbit into the Ieft antrum; (3) through both maxillae, more on the Ieft with commutation of the waI1 of the antrum; (6) through the mandibIe in the right cuspid region. (Fig. I.) Diagnosis. MuItipIe fractures of the skuI1 incIuding fractures through the cribriform pIate and posterior waI1 of both fronta sinuses with compound fracture of upper and Iower jaw; concussion and edema of the brain. Treatment of the Craniocerebral In,jury. The nonoperative procedure was carried out. There was no intracrania1 pressure, since there was constant discharge of cerebrospinal fluid through the fractured cribriform plate and, therefore, treatment of this complication was not indicated. Treatment of Lower Jaw. With intermaxiIIary eIastics attached to orthodontia bands on the incisors, both haIves of the Iower jaw were kept in proper alignment. When the correct aIignment was obtained, the orthodontia bands were converted to a retention appIiance by uniting them with a soIdered bar. The object of the appIiances is to reduce the dispIacement of the fragments, to obtain correct aIignment of the teeth and maintain the space of the missing central incisor. Without the
464 * merican
Journal
of Surgery
Garfin-Fractures
retention appliances there wouId very IikeIy be contraction of the mandibIe at this point resuIting in a V-shaped arch and hopeIessIy
of SkuII
and Jaws
JUNE,1941
suIted in a return of some fresh and oId bIood. No attempt was made to do any intra- or extranasa1 operations. It is noteworthy that
FIG. 4. Plaster cap with attachments. A, pIaster cap; B-B', hooks imbedded in pIaster; c-c’, elastics for upper jaw traction; D-D’, wire arms in sleeves of upper pIate; E-E’, extension for forward traction of Iower jaw.
distorted norma occIusion. An externa1 expanding orthodontia appIiance6 and an interna expanding apphance’ were adjusted and Iigated to the teeth of the Iower jaw. (Fig. 2.) The Mershon arch was Ieft in pIace for eight months to act as a retention apphance after union took pIace and after the Angie arch was removed. Treatment of the Upper Jaw. A meta pIate was constructed with side sIeeves for the insertions of heavy wire arms. The pIate was now pIaced into the mouth and the side arms, made of heavy coat hanger wire, were inserted into the sIeeves of the pIate. By means of heavy eIastics the side arms were attached to hooks imbedded in a previousIy appIied pIaster cap around the head. The mandibIe, Iikewise, by means of heavy eIastics was puIIed upward and attached to a stee1 arm imbedded in the pIaster cap. (Figs. 3 and 4.) With these appIiances in pIace, and not withstanding the muItipIicitv of the fractures the patient was abIe to mastIcate semisoIid foods at the end of four weeks. Through a11 this period, norma occIusion was maintained. Complications. On November 26, 1937 an abscess in the submaxiIIary region was opened and drained. On December I, 1937 an abscess in the submental region was Iikewise opened and drained. Irrigation of the Ieft antra re-
at no time did the patient compIain of headaches. Since there was ampIe drainage of cerebrospina1 ffuid through the fractured cribriform pIate, it is IogicaI to assume that headache from increased intracrania1 pressure was thereby removed. Indeed, on onIy two occasions was any appreciabIe quantity of fluid obtained by Iumbar puncture. This was on the third and fourth days after his admission to the hospita1. Two other Iumbar punctures done on the seventh and ninth days after admission yielded a smaI1 amount of cIear fluid. SUMMARY I. A statistica anaIysis of 4, IOO cases of fractures of the skuI1 is submitted. 2. An outIine of the nonoperative treatment of craniocerebra1 injuries is presented. 3. Report of a case of muItipIe fractures of the skuII with crania1 invoIvement compIicated by compound fractures of the upper and Iower jaw is given. The treatment of the jaw compIications with orthodontia appIiances is described in detai1. 4. In spite of fracture through the cribriform pIate and the posterior waI1 of both fronta sinuses with marked rhinorrhea and cerebra1 edema, the patient made a com-
Garfin-Fractures
NEW SERIES VOL. LII, No. 3
pIete ment
recovery under as described.
conservative
manage-
REFERENCES I. RAMSDELL, EDWIN G. SkuII fractures,
loo consecutive cases. Am. J. Surg., 32: 448-51, 1936. 2. MOCK, HARRY et aI. J. A. M. A., 97: 1430, 1931. 3. MUNRO, DONALD, New England J. M., 203: 502, 1930; 210: 287 and I 145, 1934.
of SkuII
and
Jaws
American .~ourna~of Surgery
465
New 4. MUNRO, DONALD. Cranio Cerebra1 Injuries. York, 1938. Oxford University Press. 5. GUARDIGIAN, E. S. and SHAWAN, H. K. Management of skuI1 fractures involving the frontal sinus. Ann. Surg., 95: 27, 1932. 6. ANGLE, E. H. AppIied Orthodontia, 3rd ed., p. 204. Dr. J. D. McCoy. PhiIadeIphia, 1931. Lea & Febiger. 7. MERSHON, JOHX V. AppIied Orthodontia, 3rd ed., p. 209. Dr. J. D. McCoy. Philadelphia, 1931. Lea & Febiger.
ONCE heart faiIure develops during pregnancy, the patient must be kept in hospita1 or under hospitaI conditions tiII delivered. From-“The Heart in Pregnancy and the ChiIdbearing Age”-by Burton E. HamiIton and K. Jefferson Thomson (Little, Brown and Co.).
OF THE SKULL COMPLICATED
BY FRACTURES SAMUEL
W.
OF THE JAWS* GARFIN,
M.D.
Junior Visiting Surgeon on Aura1 Service, Boston City HospitaI BOSTON,
M
MASSACHUSETTS
TJLTIPLE
fractures of the skuII complicated by fractures of the upper and Iower jaws are of comparativeIy infrequent occurrence. Even large chnics report reIativeIy few cases. When one searches the Iiterature to obtain aid in the handhng of these comphcated cases, one is struck by the paucity of the reports and more so by the vagueness as to For this reason the their management. author believes that a detaiIed description of this case and its treatment wiI1 be a vaIuabIe contribution on this subject. There were approximateIy 4, IOO patients with fractures of the skuI1 admitted to the Boston City HospitaI in the twenty-five year period from rgr 5 to rg3g incIusive; 727 of these were femaIe. The ages ranged from newborn infants to ninety-two years. AI1 types of fractures were encountered, from the simpIe fracture without any intracrania1 invoIvement to the muItipIe compound type with severe brain comphcations. The sites of the fractures were either the vauIt or the base. Some were compIicated by invoIvement of the nasal sinuses, mastoid, middIe ear and jaws. There were I ,489 deaths resuIting in a mortality rate of 36 per cent. If deaths occurring the first forty-eight hours are excIuded, the mortaIity rate wouId probabIy be nearer 25 per cent. It must aIso be borne in mind that these were not seIected cases but were admissions of severeIy injured patients, many in a dying or comatose condition. Further, they were treated on the genera1 services of the hospita1 in contradistinction to those patients referred to the NeuroIogica1 Service, the statistics of which appear eIsewhere in this paper. There were thirty-four cases complicated
by fracture of the jaws, an incidence of 0.8 per cent. Twenty-eight of these were simpIe fractures, three were compound fractures and in three no mention was made in the record. In this series there were eight deaths, seven occurring within the first forty-eight hours of admission. It is estimated’ that in the United States I 12,000 skuIIs are fractured annuaIIy with 28,000 deaths, a mortaIity of 25 per cent. The greatest mortaIity occurred within the first twenty-four hours. The genera1 mortaIity rate for RamsdeII’s1 series of one hundred consecutive cases was 23.0 per cent. Mock,2 in a statistica study of 8,649 cases, showed a genera1 mortaIity rate of 20.0 per cent. The foIIowing tabIe is a statistica anaIysis of cases of fracture of the skuI1 with crania1 injuries referred to the NeuroIogicaI Department from the Genera1 Services of the hospita1. TABLE
Ratio
Living
of Occurrence
CASES
Dead
laceratml
Total
series.
_.
Tota’
I
______ 63 .a nonoperable cases.. o.9ronc”sslon . 18.2 edema and congestion 25.7 cOnt”SLO*. *3,0.,,,..,.,...,........... 17.3
Mortality Per Cent
~-___
652 II 226 292
106 0
758 II
3 17
229 309
I.3 5.5
123
86
209
41.1
250
1203
20.7
953
‘3.9 0.
19.8
From the tabIe above, it may be seen that the nonoperabIe cases comprise 63.0 per cent. Under the methods of treatment as carried out at the Boston City HospitaI, the immediate mortaIity has remained about 14.0 per cent. This is figured from a11 such cases without regard to the time of their death after
* From the Aura1 Service of the Boston City Hospital, 460
I
NONOPERABLE
Boston,
Massachusetts.
NEW SERIES VOL. LII,
No.
3
Garfin-Fractures
admission to the hospita1. Since these figures are from admissions to speciahzed service (NeuroIogicaI Service of the Boston City Hospital), from a genera1 hospita1 they tend to be higher rather than Iower as cited above. It is impossibIe to standardize the treatment of a11 craniocerebrar injuries, as each individua1 case presents its own requirements. The character of the pathology must, in the Iast analysis serve as a guide for the kind of treatment. The folIowing is an outline of the nonoperative care which I empIoy in the great majority of cases. This is not to impIy that operative indications in this group shouId be ignored. TREATMENT
A summary of the non-operative treatment in craniocerebral injuries and as carried out in this case foIIows: (I) Rest in bed; (2) no morphine; (3) combat shock; (4) combat increased intracrania1 pressure by (a) magnesium suIphate, (b) hypertonic glucose soIution intravenousIy, (c) Iumbar revent dehydration; (6) drainage; (5) p prevent starvation; (7) IocaI treatment, (a) scaIp wounds, compound fractures, (6) discharge from ear and nose (sinuses), (c) other injuries; (I) fracture through the sinuses, (2) fracture of the jaws, etc. Deh.ydration methods are based on the fact that hypertonic soIutions wiI1 withdraw fluids from the body tissues into the blood stream by a process of osmosis. In doing this, the brain is Iikewise depIeted, thus Iessening the increasing edema which h as foIIowed the cerebra1 injury. This method is considered new, yet oId writers on skuI1 fractures advocated rest and purging of the patient as the proper Iine of treatment. Magnesium suIphate 4 ounces, 50 per cent soIution is administered as retention enema and repeated every four to six hours during the first forty-eight hours. GIucose, 50 cc. 50 per cent soIution or I00 cc. 25 per cent solution intravenousIy (steriIe) may be repeated every eight or twelve hours. Glucose mavY be given during c3 the shock~.
of Skull
and Jaws
A merican
Journal
of Surgery
1 61
period. During the first forty-eight hours, Auid intake is restricted; after forty-eight hours fluids may be pushed. The remaining cases are treated as foIIows : Concussion. There being no signs or symptoms of crania1 pathoIogy, except tota unconsciousness, after recovery is compIete and all symptoms have disappeared, treatment other than rest in bed and supportive care is neither indicated nor required. Edema and Congestion. Treatment is directed to shrinking of the brain by dehydration or the remova of the excess of backed-up cerebrospina1 fluid by Iumbar drainage. Dehydration may be carried out by intravenous injection of hypertonic glucose soIution or magnesium suIphate by rectum. With Iumbar puncture, enough cerebrospina1 fluid is removed to reduce an abnormaIIy high pressure to normal Iimits, This shouId be repeated every twenty-four hours unti1 two successive norma pressure measurements have been obtained previous to withdrawa of any fluid. Contusion and Laceration. Treatment is best carried out by a judicious combination of dehydration and Iumbar drainage. Munro3 states that dehydration aIone is inefhcient in these cases in exact ratio to the amount of free bIood in the cerebrospina fluid. This is due to the mechanica bIockage of the arachnoida1 viIIi by the free red bIood ceIIs. Operative decompression as a therapeutic measure is contraindicated. Exploratory trephination, however, can b e properIy empIoyed as a diagnostic measure whenever the patient faiIs to improve after a suitabIe interva1 of properIy executed nonoperative treatment such as outIined above. CerebrospinaI rhinorrhea may, however, prove to be very serious. It is not uncommon in frontal sinus fractures5 and is due invariabIy to a fracture of the cribriform plate” in which a funnel-shaped fragment of the dura and arachnoid has been caught in the fracture line. Munro4 beheves fata meningitis is a certainty unIess the fistuIa
462
A merican Journal of Surgery
Garfin-Fractures
is closed. Packing, irrigation or blowing of the nose should be forbidden. Fractures involving the frontal sinuses
of SkuII and Jaws
JUNE, ,941
hospita1 on the morning of NoveInber 15 in a dazed and semiconscious condition and bled profusely from ;he mouth and nose.
to a nearby
FIG. I. Photograph
of x-ray fiIm showing fractures invoIving the posterior wall of both fronta sinuses, the cribriform pIate, the outer angle and the floor of the left orbit, the Ieft malar, both maxillae and a fracture of the mandibIe at the sgmphisis.
0nIy form a small percentage of our tota cases. Guardigian and Shawan,5 in a series of 2,600 cases of skuII fractures, found an incidence of 5.0 per cent of fronta sinus involvement. The majority of these were asymtomatic and recovered under conservative treatment. Where the posterior waII was invoIved with threatening intracrania1 compIications operation is indicated. CASE
REPORT
A white maIe accountant, age thirty-one, while waIking was struck by a moving auto14, 1937. He Iost conmobiIe on November sciousness immediateIy and was not cIear as to the detaiIs of the accident, but apparentIy he was unconscious for the greater part of the night of November 14 and 14. He was taken
On November 16, he was admitted to the Aural Service of the Boston City HospitaI. The examination was as foIIows: The patient was semiconscious and incoherent. 100.2“~. rectaIIy, 84, 12 B.P. 136/62. T.P.R., The head is described beIow. The right pupil reacted sIuggishIy. ExtraoccuIar movements appeared normaI. The fundus of the right eye (which was the onIy one that could be examined), showed no choking. The ear drums were normal; the abdomen was soft; the bladder was enIarged somewhat; the inguina1 region and genitaIia were negative. Rectal examination showed a scar, presumabry from an ischeorecta1 abscess, to the right of the anus. Prostate was normal. There was some feces in the rectum. The arms and Iegs showed the Iacerations described beIow. PuIses were norand equal. ma1 ; reflexes were hyperactive There was Ieft ankIe c1onu.s but no Bahinski
NEW SERIES VOL. LII. No.
3
Garb-Fractures
or Hoffmann. AbdominaI reflexes obtained. The patient’s past history was
Flc.
were
of Skull and Jaws not
irreIative
2. PIaster mode1 of lower jaw with orthodontia appIiances in pIace. Note the teeth Iigated to externa1 arch wire and the expanding arch on the Iingual surface.
except for an operation for an ischeorectal abscess a year before. There was a ragged Iaceration of the chin and a through-and-through Iaceration of the Iower Iip. The Iower teeth were Ioosened and the Iower right centra1 incisor was missing from an open socket which had a purulent discharge. There was a compound fracture of his Iower jaw through the mucous membrane of the mouth and gums; the fracture line was just to the right of the midIine. The entire jaw was markedIy swoIIen, the upper and Iower lips were Iacerated, and there was considerabIe drooIing of blood and saIiva. The upper jaw was Ioose, dispIaced downward and both centra1 incisors were fractured at their gingiva1 margins. OccIusion was impossibIe. The tongue was markedly swoIIen. The patient was unabIe to swaIIow. There was induration and sweIIing in the right submaxiIIary region extending to the midIine with areas of tenderness over the thyroid cartiIages. The nose was swoIIen, bIeeding and dispIaced toward the right with a depressed fracture of the nasa1 bones and the ascending process of the maxiIIa on the left side. Anterior rhinoscopy showed marked congestion of the entire nasa1 mucosa; the septum was dispIaced toward the right side; the turbinates were engorged and soggy looking, there was considerabIe discharge of mucus, blood and cerebrospina1 fIuid. Posterior rhinoscopy was impossibIe because of the enormous sweIling of tongue and downward dispIacement of the maxiIIa. The soft paIate and uvuIa were mark-
A merican JOUST ofsurgcry
463
There was Iaceration and edIy edematous. abrasion over the upper eye lids with subconjunctival haemorrhage in both eyes. There was
FIG. 3. Plaster model of upper jaw with cast metal pIate and side arms in pIace. considerabIe sweIIing at the outer edge of the Ieft orbita border merging with the maIar bone on that side. X-ray examination reveaIed the folIowing: Left stereo and A.P. of the skuI1 showed muItipIe fractures: (I) through the posterior waI1 of both fronta sinuses; (2) through the cribriform pIate; (3) through the outer angIe of the Ieft orbit; (4) through the floor of the orbit into the Ieft antrum; (3) through both maxillae, more on the Ieft with commutation of the waI1 of the antrum; (6) through the mandibIe in the right cuspid region. (Fig. I.) Diagnosis. MuItipIe fractures of the skuI1 incIuding fractures through the cribriform pIate and posterior waI1 of both fronta sinuses with compound fracture of upper and Iower jaw; concussion and edema of the brain. Treatment of the Craniocerebral In,jury. The nonoperative procedure was carried out. There was no intracrania1 pressure, since there was constant discharge of cerebrospinal fluid through the fractured cribriform plate and, therefore, treatment of this complication was not indicated. Treatment of Lower Jaw. With intermaxiIIary eIastics attached to orthodontia bands on the incisors, both haIves of the Iower jaw were kept in proper alignment. When the correct aIignment was obtained, the orthodontia bands were converted to a retention appIiance by uniting them with a soIdered bar. The object of the appIiances is to reduce the dispIacement of the fragments, to obtain correct aIignment of the teeth and maintain the space of the missing central incisor. Without the
464 * merican
Journal
of Surgery
Garfin-Fractures
retention appliances there wouId very IikeIy be contraction of the mandibIe at this point resuIting in a V-shaped arch and hopeIessIy
of SkuII
and Jaws
JUNE,1941
suIted in a return of some fresh and oId bIood. No attempt was made to do any intra- or extranasa1 operations. It is noteworthy that
FIG. 4. Plaster cap with attachments. A, pIaster cap; B-B', hooks imbedded in pIaster; c-c’, elastics for upper jaw traction; D-D’, wire arms in sleeves of upper pIate; E-E’, extension for forward traction of Iower jaw.
distorted norma occIusion. An externa1 expanding orthodontia appIiance6 and an interna expanding apphance’ were adjusted and Iigated to the teeth of the Iower jaw. (Fig. 2.) The Mershon arch was Ieft in pIace for eight months to act as a retention apphance after union took pIace and after the Angie arch was removed. Treatment of the Upper Jaw. A meta pIate was constructed with side sIeeves for the insertions of heavy wire arms. The pIate was now pIaced into the mouth and the side arms, made of heavy coat hanger wire, were inserted into the sIeeves of the pIate. By means of heavy eIastics the side arms were attached to hooks imbedded in a previousIy appIied pIaster cap around the head. The mandibIe, Iikewise, by means of heavy eIastics was puIIed upward and attached to a stee1 arm imbedded in the pIaster cap. (Figs. 3 and 4.) With these appIiances in pIace, and not withstanding the muItipIicitv of the fractures the patient was abIe to mastIcate semisoIid foods at the end of four weeks. Through a11 this period, norma occIusion was maintained. Complications. On November 26, 1937 an abscess in the submaxiIIary region was opened and drained. On December I, 1937 an abscess in the submental region was Iikewise opened and drained. Irrigation of the Ieft antra re-
at no time did the patient compIain of headaches. Since there was ampIe drainage of cerebrospina1 ffuid through the fractured cribriform pIate, it is IogicaI to assume that headache from increased intracrania1 pressure was thereby removed. Indeed, on onIy two occasions was any appreciabIe quantity of fluid obtained by Iumbar puncture. This was on the third and fourth days after his admission to the hospita1. Two other Iumbar punctures done on the seventh and ninth days after admission yielded a smaI1 amount of cIear fluid. SUMMARY I. A statistica anaIysis of 4, IOO cases of fractures of the skuI1 is submitted. 2. An outIine of the nonoperative treatment of craniocerebra1 injuries is presented. 3. Report of a case of muItipIe fractures of the skuII with crania1 invoIvement compIicated by compound fractures of the upper and Iower jaw is given. The treatment of the jaw compIications with orthodontia appIiances is described in detai1. 4. In spite of fracture through the cribriform pIate and the posterior waI1 of both fronta sinuses with marked rhinorrhea and cerebra1 edema, the patient made a com-
Garfin-Fractures
NEW SERIES VOL. LII, No. 3
pIete ment
recovery under as described.
conservative
manage-
REFERENCES I. RAMSDELL, EDWIN G. SkuII fractures,
loo consecutive cases. Am. J. Surg., 32: 448-51, 1936. 2. MOCK, HARRY et aI. J. A. M. A., 97: 1430, 1931. 3. MUNRO, DONALD, New England J. M., 203: 502, 1930; 210: 287 and I 145, 1934.
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Jaws
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New 4. MUNRO, DONALD. Cranio Cerebra1 Injuries. York, 1938. Oxford University Press. 5. GUARDIGIAN, E. S. and SHAWAN, H. K. Management of skuI1 fractures involving the frontal sinus. Ann. Surg., 95: 27, 1932. 6. ANGLE, E. H. AppIied Orthodontia, 3rd ed., p. 204. Dr. J. D. McCoy. PhiIadeIphia, 1931. Lea & Febiger. 7. MERSHON, JOHX V. AppIied Orthodontia, 3rd ed., p. 209. Dr. J. D. McCoy. Philadelphia, 1931. Lea & Febiger.
ONCE heart faiIure develops during pregnancy, the patient must be kept in hospita1 or under hospitaI conditions tiII delivered. From-“The Heart in Pregnancy and the ChiIdbearing Age”-by Burton E. HamiIton and K. Jefferson Thomson (Little, Brown and Co.).