Peter J.

Koltai

Trauma is the leading cause of death and disability of

Americans younger than 40 years (1 ). In the United States,
more than 150,000 violent deaths occur each year, and
more than 500,000 trauma victims are left with permanent disabilities. Annually, approximately 30 to 40 million
visits are made to emergency departments for injury treatment (2). The cost to our society is significant. In 2000,
$117 billion was spent by Americans, which accounts for
10% of all medical expenditures (3). This is comparable to
the percentages attributable to other public health issues
such as obesity (9.1%) and smoking (14.4%) (4).
Deaths from trauma fall into three categoriesimmediate,. early, and late. Immediate death occurs within
minutes of injury and is caused by acute airway obstruction
or major vessel disruptions of the brain, heart, or other
internal organs. Early death occurs in the first few hours
after injury and is associated with excessive hemorrhage,
blood accumulation around the brai~ or respiratory failure. Late death occurs days to weeks after trauma and is
caused by sepsis and multiple organ failure.
More than half the deaths due to trauma occur within
several minutes of the accident. Because immediate treatment is rarely available, accident prevention is the most
logical way to decrease this number. Many public health
injury prevention strategies have been successfully implemented including use of seat belts (5) and bicycle helmets
(6), implementation of blood alcohol limits (7), and fire
safety education including widespread smoke alarm use
(8). Early deaths account for about one-third of all trauma
deaths. Although not all of these patients can be saved,
many can be treated effectively with rapid and definitive
response. This requires a parallel system of coordinated prehospital care and hospital care at dedicated trauma centers.
Death at an accident scene is usually related to head
injury with associated hypoventilation due to loss of
consciousness. Intubation in the field can thus be lifesaving. Massive hemorrhage is another common cause of

James Chan

prehospital death. When intravenous catheters are inserted

at the scene, circulatory volume can be maintained until
the hemorrhage can be surgically controlled. Rapid transport to a hospital with an organized team of surgeons,
anesthesiologists, and trauma professionals is vital for
the effective treatment of trauma patients. In urban areas,
ambulances usually provide efficient transportation to the
hospital. In rural areas, distance becomes a critical factor
and helicopters or airplanes can be lifesaving.
Trauma patients undergo rapid and severe changes in normal body function, including hemorrhage, tissue hypoxia,
cellular damage, and disrupted function of vital organs. The
physiologic response to massive injury is dramatic and occurs
both systemically and locally. Systemic responses include
activation ofthe clotting sequence, shifts ofextravascular fluid
into the drculatoty system, redistribution of blood flow to
the heart and brain, and alterations in renal and pulmonaty
function to maintain add-base balance. Metabolic changes
include skeletal muscle and fat breakdown to provide substrate for the body's fuel-intensive response to trauma. Local
responses include immunologic activation with leukocytes
mobilization, awte-phase protein synthesis, inflammatory
cell migration into the injured area, and onset of fibroblast
proliferation and blood vessel ingrowth to begin the wound
repair process. Understanding the restorative mechanisms
that occur in an acutely injured patient is necessaty for the
complex: task of treating these patients with regard to fluid
maintenance, nutritional requirements, wound healing, and
susceptibility to infection (9,10).

NEUROENDOCRINE RESPONSE
Hemostatic adjustments to trauma are mediated by the
neuroendocrine system. Stimuli such as hemorrhage,
hypoxia, and tissue damage stimulate a graded response
that increases to a peak level, after which additional
response is no longer possible. Pain is the first signal from

1093

1094

Section V: Trauma

the central nervous system ( CNS) to reestablish homeostasis. The hypothalamic response to pain stimulates the
pituitary gland to release corticotropin, which stimulates
adrenal secretion of cortisol. Pain causes elaboration of
antidiuretic hormone for fluid conservation. Pain activates
the sympathetic nervous system and stimulates direct adrenal secretion of epinephrine.
Blood loss stimulates vascular pressure and volume
receptors and precipitates a eNS-mediated decrease in cardiac output, an increase in peripheral vascular resistance,
and redistribution of blood flow to vital organs. Hypoxia
and hypercapnia cause chemoreceptor stimulation, vasomotor activation, and increased respiratory drive. At later
stages, stimulation of the hypothalamus by interleukin
1 initiates the hypermetabolic response to injury manifested by the elevated temperatures experienced by injured
patients (11, 12).
The hormonal response to trauma is marked by a rise
in the catabolic hormones, corticotropin, cortisol, growth
hormone, glucagon, epinephrine, and norepinephrine. In
contrast, plasma concentrations of the primary anabolic
hormone, insulin, are decreased due to CNS-mediated
sympathetic inhibition of the pancreas. Posttraumatic
hyperglycemia provides non-insulin-mediated tissues
such as the brain with a preferential supply of glucose.
Glucagon, cortisol, and catecholamines maintain blood
glucose levels and prevent hypoglycemia. The primary
function of glucagon, which is produced in the pancreas,
is to promote gluconeogenesis in the liver. After trauma,
direct sympathetic stimulation of the pancreas enhances
glucagon secretion. Corticotropin release by the anterior pituitary gland causes adrenal production of cortisol,
which promotes the breakdown of skeletal muscle into
amino adds and facilitates gluconeogenesis in the liver.
The hypoglycemic effect of cortisol counteracts insulin.
Release of catecholamines is the most fundamental hormonal reaction to trauma. Epinephrine, released by the
adrenal medulla in response to direct neurostimulation, is
a potent regulator of the circulatory system and systemic
metabolism. Epinephrine's hemodynamic effects include
vasoconstriction, increased cardiac rate, and increased
myocardial contractility and conductivity. Epinephrine also
promotes glucose production by enhancing hepatic gluconeogenesis and inhibiting insulin release. Norepinephrine,
the primary sympathetic nervous system neurotransmitter, exerts a direct effect on the circulatory system and
vital organs. With massive and prolonged sympathetic
discharge, norepinephrine can enter the bloodstream and
exerts a direct vasoconstrictive effect on the vascular system
similar to that of epinephrine ( 9, 10).

METABOLIC RESPONSE
The postinjury period is characterized by catabolism.
Negative nitrogen balance, hyperglycemia, and heat production reflect the increased energy requirements for

ongoing reparative and inflammatory processes. Increased

energy expenditure is due to sustained release of circulating catecholamines and increased activity of the sympathetic nervous system. The primary energy source during
this period comes from oxidation of lipids promoted by
the elaboration of the catabolic hormones (9, 10).
Although fat is the primary energy source after injury,
protein is also broken down to produce energy. In a fasting catabolic patient. glucose can be generated only from
the breakdown of protein. lipid breakdown to triglycerides
and glycerol contributes minimally to form precursors for
the synthesis for new glucose. As a result, protein is rapidly
broken down to form precursors for new glucose synthesis
in a trauma patient in the catabolic state. The result is rapid
loss of muscle mass. The depth and the length of the catabolic state are related to trauma severity. Although it represents an adaptive mechanism, a persistently prolonged and
severe catabolic state leads to severe malnutrition, multiple
organ failure, and death (9,10,13-15).

TREATMENT OF A PATIENT WHO HAS

SUSTAINED TRAUMA
The key to improving survival and managing disability in
the trauma patient are the initial evaluation and resuscitation performed at a dedicated trauma center. The American
College of Surgeons has developed a protocol taught in
advanced trauma life support courses to improve the care
of injured patients during the early hospital phase. It is
based on a primary and secondary survey approach that
allows physicians to handle the complex. multisystem
problems of trauma patients. This treatment algorithm can
be divided into four categories-primary survey, resuscitation, secondary survey, and definitive care.
The primary survey involves hierarchical assessment of
airway, breathing, and circulation. The purpose is to identify extreme, life-threatening injuries and institute immediate life-sustaining maneuvers. Resuscitation is performed
simultaneously with the primary survey. The secondary
survey consists of a rapid but systematic head-to-toe physical examination with the patient completely disrobed. This
global assessment is done to identify all potentially lifethreatening and occult injures. An important part of the
primary and secondary survey are radiographic studies
including the use of ultrasonography. Samples are drawn
for baseline blood studies, typing, and cross-matching.
Once these priorities have been addressed, vital signs
are rechecked. When the patient's condition is stable, a
detailed management plan is established.

Primary Survey
Airway
The foremost emergency measure is establishing the airway, which may be lost to a variety of causes. The oropharynx,. larynx, and trachea can be obstructed by secretions,

Chapter 74: Principles of Trauma

blood, and foreign bodies. Oropharyngeal airway collapse

can ocrur with loss of consciousness and from facial fractures (Chapter 78). Direct trauma to the larynx and trachea
may cause airway obstruction below the oropharynx (see
Chapter 77). Manueven to secure an adequate airway
range from the simple to the complex and begins with
manual cleaning of the oropharynx followed by suctioning
of secretions (Chapter 63).
The primary risk during early airwaymanagm~ent is neck
movement when there is an occult ce:rvical spinal fracture.
The airway must be controlled with the assumption that
such a fracture exists. The neck must be completely imm~
bilized in a neutral position. One member of the trauma
team must be assigned to kneel at the head of the stretcher
to maintain inline manual head stabilization and avoid
hyperextension by holding the cerrical spine with the hands
while immobilizing the head with the forearms (Fig. 74.1).
'Iiaction on the head is avoided, because distraction with
further injwy to the spinal cord can occur if the patient
has an unstable ce:IVi.cal spinal injw:y. Once the neck of an
unconscious patient has been secured forward traction of
the mandible is performed to overcome pharyngeal collapse
(Fig. 74.2). The nat step is oropharyngeal airway placement in the unconscious patient If the patient is conscious,
a nasopharyngeal airway is used. Once the airway has been
established and the patient is spontaneously breathing, supplemental oxygen can be provided through nasal prongs or
a face mask
When these simple measures are unsuccessfut more
aggressive airway management is needed. Nasotracheal
intubation is the preferred technique for establishing an
airway in a conscious patient who may have a cervical spinal injwy because it can be done without excessive neck
mobility. Nasotracheal intubation is better tolerated by an

1095

Figure 74.1 Stablllzadon of the a~rvlcal spine during primary

survey of an Injured patient.

awake patient than is orotracheal intubation and does not

necessitate sedation or muscle relaxation. Nasotracheal
intubation is precluded if the patient has extensive
maxillofacial injuries.
If the nasotracheal route cannot be used, orotracheal
intubation is the next step. In ideal circumstances, a crosstable lateral cervical spine radiograph is obtained before
orotracheal intubation to evaluate for a possible cerrical
spinal fracture. It is nevertheless important to remember that even a normal cross-table lateral radiograph of
the cervical spine does not definitively exclude the p~
ence of cervical spinal fracture or instability (16). When
emergency airway control with orotracheal intubation is
indicated, intubation proceeds with inline stabilization
whether or not radiographs have been obtained. Bag-mask
intubation can be an effective method of maintaining
the airway Wltil radiographs are obtained. If the patient
is unconscious and cervical spinal injw:y has been ruled

Figure 74.2 Once the neck of an unconscious patient has been secured, forward traction of the
tongue and mandible Is performed.

1096

Section V: Trauma

out,. orotracheal intubation can be readily accomplished.

A patient who is awake must be paralyzed with succinylcholine for successful orotracheal intubation.
After intubation, the chest is auscultated to ensure
that the tube is in the trachea and not in the esophagus
or in one of the mainstem bronchi. Correct endotracheal
tube positioning can be confirmed reliably by the presence of end-tidal ca:rbon dioxide. Carbon dioxide from
the lungs can be detected rapidly by observing a color
change on a disk that can be connected rapidly to the
endotracheal tube. If no carbon dioxide is detected, the
endotracheal tube is in the esophagus, and a new airway is attempted. If the patient is in cardiac arrest,. endtidal carbon dioxide is unreliable in confirming the
positioning of an endotracheal tube. A follow-up chest
radiograph to confirm the position of the tube must be
obtained expeditiously.
If an endotracheal tube cannot be inserted, as when a
patient has major facial fractures or has sustained laryngotracheal trauma. surgical airway intervention may be
needed. 1here are four surgical methods of obtaining an
airway-needle ai.cothyrotomy, conventional cricothyrotomy, tracheotomy, and percutaneous transtracheal
ventilation.
For children, needle cricothyrotomy is the best
procedure. The procedure is performed by placing a number 12 or number 14 intJ:aven.ous cannula with a plastic
sheath through. the cricothyroid membrane into the tracheal lumen. Once in the airway, the needle is withdrawn
and the plastic sheath is advanced. When properly positioned, the sheath is connected with intravenous tubing to
wall or bottled oxygen at 50 pounds per inch of pressure
(about 15 L oxygen per minute). Ventilation is accomplished by means of 1-second intermittent injections of
oxygen followed by 4-second exhalations. Patients can be
maintained for up to 30 minutes with this technique, after
which hypercapnia becomes a problem.
Surgicalcricothyrotomyisthepreferredapproachforadult
patients who need surgical airway inklvention {Fig. 74.3).
It consists of a small vertical skin incision over the area of
the cricothyroid membrane followed by a horizontal incision through. the cricothyroid membrane itself. 1he blunt
end of the scalpel is inserted between the cricoid and the
thyroid cartilages and rotated 90 degrees to make an opening through. which an endotracheal tube or tracheostomy
tube can be inserted.
For patients with laryngeal trauma, tracheal trauma,
or ttacheal disruption. aicothyrotom:y is inadvisable, and
eme~gency tracheotomy is performed. Percutaneous transtracheal ventilation, a technique similar to needle cricothyrotomy, is an acceptable alternative in the treatment
of these patients. In the trauma patient, continuous pulse
oximetty monitoring is extremely helpful in determining
the adequacy of oxygenation and is used in the care of all
critically injured patients to allow early detection of arterial
oxygen desatwation.

Knife handle in
cricothyroid
membrane
rotated 90

Figure 74.3 Crlcothyrotomy.

Chapter 74: Principles of Trauma

Breathing
Loss of respiratory drift among trauma patients is most
commonly caused by severe head trauma. Ventilation
is provided with a bag-mask until cervical spinal injury
is ruled out. An endotracheal tube is then inserted, and
mechanical ventilation begun. & part of the primary survey, injuries to the chest wall and structures within the
thoracic cavity that can cause hypoventilation must be recognized and rapidly managed. These injuries include sucking pneumothorax. massive pneumothorax. and tension
pneumothorax.
Sucking pneumothorax occurs when there is a defect in
the chest wall larger than the tracheal diameter. Because
of reduced resistance through this opening, inspiratory
and expiratory efforts result in movement of air through
the opening in the chest wall into the pleural space rather
than through the trachea. Occluding the chest wall defect
and chest tube placement followed by intubation with
positive pressure ventilation is the best management of
this injury.
Massive hemothorax is vented promptly. .Although
blood loss of 1,000 to l,SOO mL into the thoracic cavity
almost always necessitates emexgency thoracotomy, initial
management is aimed at decompressing the chest cavity so
that adequate ventilation can proceed. TUbe thoracotomy
is performed by means of making an incision at the fourth
or fifth intercostal space in the midaxillacy line (Fig. 74.4).
A shon subcutaneous tunnel is developed by means of
finger dissection. and the tube is passed posterosuperiorly along an intrapleural tract toward the pleural apex.
Continued hemonhage at a rate of greater than 200 mLfh
is an indication for thoracotomy.

1097

Tension pneumothorax develops when a pleural,

bronchial, or tracheal tear allows air to be forced into the
pleural space without a means of egress. The result is collapse of the ipsilateral lung. As pleural pressure increases,
the mediastinum and trachea shift to the opposite side,
compress the contralateral lung, and compromise oxygenation. lhe mediastinal shift kinks the inferior and the
superior "rena cava; the kink impairs venous ret.um. and
hypotension develops. Signs and symptoms of tension
pneumothorax. are acute shonness ofbreath, tracheal deviation away from the injury, increased resonance to percussion, distention of the neck veins, and decreased breath
sounds over the injured hemithorax. Tension pneumothorax is a clinical diagnosis made on these clinical grounds.
Diagnostic chest radiographs should not delay chest
decompression as this may lead to the patient's death.
Tension pneumothorax is managed by means of allowing
air to escape through needle thoracocentesis with a largebore, 12-gauge intravenous cannula inserted into the second intercostal space in the middavicular line (Fig. 74.5),
followed by definitive treatment with chest tube insertion. Pneumothorax. also can cause hypotension owing
to its effect on myocardial performance. Any patient who
remains in shock after chest trauma needs empirical chest
ventilation.

Circulation and Shock

Once the airway and breathing have been reestablished,
the nat step is to assess the adequacy of the circulatory system. Shock is the clinical manifestation of the inability of
the heart to maintain adequate drculation to vital organs.
lhis low-flow state can be caused by cardiac dysfunction,

Figure 74.4 Tube! thoracostomy. All Incision Is made In the fourth or fifth Intercostal space In the

mldaxlllary line. A:. A short subcutaneous Intrapleural track Is developed by means of fingc:~r dlsSCilctlon. 1: The tube Is passed posteriorly and superiorly toward the pleural apex.

1098

Section V: Trauma

Class m hemorrhage is the loss of 30% to 40% ofblood

volume. Patients often are extremely anxious or
combative and have marked tachycardia and tachypnea. prolonged capillary refill time, and a marked
decrease in urine output. Only at this stage of severe
hypovolemia does supine hypotension occur.
Class IV hemorrhage is the loss of more than 40% of
blood volume. The result is marked hypotension
and tachycardia. Urine output is almost completely
shut off, and mental status can range from anxiety
to coma Blood loss of this magnitude is often fatal.

FiguN 74.5 Needle thoracentesis for management of pneumothorax. The needle is inserted into the second intercostal space in
the davic.llar line.

loss of blood volume, loss of vascular resistance, and an

increase in venous capacity (13). The cellular response
to shock is a shift from aerobic to anaerobic metabolism
in nonvital oxgan systems. 1he result is lactic acidosis. If
hypoperfusion pmists, oxygen delivery to vital organs
becomes inadequate, and acidosis deepens. Unless oxygenation and perfusion are restored, o~gan failure progresses,
and the patient dies.
The clinical presentation of shock depends on the seva-ity. A patient with mild shock may be anxious and restless;
if shock is severe, the patient appears listless or ezhausted.
1he skin is cool and sallow with decreased capillary :filling
in the nail beds. Thirst, nausea. and 'VOmiting are common.
Blood pressure is low, and the pulse is fast and weak. Poor
:filling of peripheral veins makes it difficult to place intravenous cathetent. There are four categories of shock-hypovolemic shock,. neurogenic shock,. cardiogenic shock,. and
septic shock. The :first three are associated with the acute
phase of trauma
Hypovolemic: Shock
Hypovolemia is the most common cause of shock after
trauma Hemorrhage is assumed to be the cause unless
proved otherwise. Attempts have been made to classify
the severity of hemorrhagic shock as follows to give better
guidelines for resuscitation:

Class I hemorrhage is the loss of about 15% of blood

volume. The primary manifestation is mild anxiety.
Class II hemorrhage is the loss of 15% to 30% of blood
volume. 1he result is tachycardia and tachypnea. anxiety, decreased capillary refill, and decreased urine
output Supine blood pressure remains normal.

Hypovolemia should be managed with rapid volume

replacement. Patients needing acute fluid resuscitation
are usually those in whom venous access is most difficult.
For most patients, 14-gauge intravenous catheters can be
inserted into the antecubital veins with little difficulty. If
the systolic blood pressure is so low that percutaneous
access in the antecubital spaces is precluded, greater saphenous vein cutdown can be performed. Percutaneous femoral vein or subclavian catheterization is another altmaa~,
but the surgeon must be familiar with the anatomic featuret of the area (1-7,10,12).
Crystalloids, such as lactated Ringer solution or normal
saline solution. are the preferred fluids for resuscitation.
In adults, blood volume is about 7% of total body weight
(about 5 L for a normal-sized man). In children, blood volume is 8% or 9% of total body weight; in infants, 10%.
1he requirements for crystalloid resuscitation can be based
on the results of clinical assessment of the percentage of
blood loss and the lmowledge of the approximate blood
volume of the patient. Circulating volume can be restored
by infusing 3 mL crystalloid solution for each milliliter of
estimated blood loss. This ratio can be much greater in
massive hemorrhage. The crystalloid solution is infused
as rapidly as possible until blood pressure and heart rate
return to acceptable levels. Further fluid replacement can
be monitored according to the adequacy of the urine output (1-7,10,12).
When crystalloid replacement is inadequate, blood
replacement becomes necessary. As a rule, trauma patients
who arrive in the emexgency department with supine hypotension likely need transfusion. Blood is added to resu
citation when the crystalloid infusion exceeds SO mL/kg.
Cross-matched, type-specific blood rarely is available
to acutely injured patients, but un-cross-matched typespecific whole blood can be obtained rapidly in most
hospitals and rarely causes serious complications. If typespecific blood is unavailable, type 0-negative (universal
donor) blood can be given safely to a trauma patient in
need of emergency blood transfusion. 1he risk of transfusion reactions with 0-negative blood in this situation is
minimal.
Substantial clotting problems can occur with massive
crystalloid and blood replacement therapy for hemorrhagic shock. Although blood components are not used

Chapter 74: Principles of Trauma

in early resusdtatio~ dilutional coagulopathy can develop

after substantial transfusion. This dilutional coagulopathy is managed with fresh-frozen plasma and platelet
transfusion, depending on the degree of ongoing bleeding. Platelets and fresh-frozen plasma are administered
according to the degree of coagulopathy. not the specific
number of units of blood administered. As a rule, using
fresh-frozen plasma can be considered after the tenth unit
of banked blood and then after every fourth unit. Use of
platelets can be considered after the fifteenth unit of blood,
and then after every fifth unit. Coagulation profiles can be
monitored.
Adjunctive steps can be helpful in the care of patients
sustaining hemorrhagic trauma. In cases of external hemorrhage, the bleeding often can be controlled with minimal pressure. Tourniquets usually are not helpful, because
direct compression can control blood loss. Blind damping must be avoided to prevent injury to adjacent nerves.
The scalp may be the source of profuse bleeding. and rapid
temporary suturing may be needed.
Military antishock trousers (MAST), which are inflatable
pants, can be placed around the patient's legs and pelvis to
decrease circulation to the extremities and thereby improve
central circulation. They are not meant to replace adequate
fluid therapy but can be useful in the prehospital phase
of the trauma delivery system. Caution must be exercised
in using MAST because abdominal compartment inflation
can impair respiratio~ and leg compartment overinflation
for long periods can cause compartment syndrome.
Neurogenic Shock

The purpose of fluid restoration is to reestablish adequate

perfusion to vital organs. Measurements such as blood
pressure, heart rate, urinary output, and level of consciousness help measure the success of fluid resuscitation. When
these signs do not change in response to adequate resuscitation, other causes must be suspected. One such cause
can be neurogenic shock. which is caused by brainstem
dysfunction or spinal cord injury that denervates the sympathetic nervous system. The result is vasodilatation and
decreased peripheral vascular resistance and consequent
loss of blood pressure. Neurogenic shock is characterized by the absence of tachycardia,. warm extremities, and
lack of anxiety in the presence of hypotension. No patient
should be presumed to have neurogenic shock, despite evidence of neurologic injury, until all other causes of shock
have been systematically evaluated and eliminated. Once
this has been done, neurogenic shock management is fluid
resuscitation to replete intravascular volume, vasopressors
to restore lost vascular tone, and appropriate neurosurgical
intervention (13).
Cardiogenic Shock

Cardiogenic shock is loss of circulatory perfusion because

the myocardium cannot produce sufficient flow to maintain
tissue oxygenation. Among trauma patients, cardiogenic

1099

shock is generally associated with three injuries: tension

pneumothorax. cardiac tamponade, and myocardial contusion. Cardiogenic shock is suspected when hypotension
persists despite appropriate resuscitation. The most common features of cardiogenic shock are distended jugular
veins and elevated central venous pressure in the presence
of hypotension. These signs may not occur until the patient
has undergone adequate fluid replacement. Cardiogenic
shock may coexist with hypovolemic shock.
A common feature of tension pneumothorax is
impaired myocardial function due to decreased venous
return. Increasing intrathoracic pressure distends the jugular veins and causes hypotension. In an emergency, tension
pneumothorax can be confused with cardiac tamponade
because both conditions are associated with hypotension
and neck vein distention. In some instances, it is impossible to differentiate these two conditions, and empiric
thoracocentesis is necessary on the side most likely to be
affected. If there is a rush of air with restoration of hemodynamic status, the diagnosis of tension pneumothorax is
confirmed. If not, the procedure is repeated on the opposite side of the chest. If the patient's condition does not
improve, cardiac tamponade is considered, and the patient
is empirically treated.
Cardiac tamponade in a trauma patient is caused by
blood accumulation between the myocardium and its
pericardia! covering. Because the pericardium is nondistensible, small volumes of blood can accumulate in the
acute setting resulting in marked myocardial impairment.
The pathophysiologic changes leading to cardiogenic shock
are caused by a decrease in ventricular filling during diastole and myocardial contractility impairment due to ischemia from coronary circulation impairment. The classic
cardiac tamponade signs are hypotensio~ jugular venous
distention, and distant heart sounds. The jugular veins may
not become distended if the patient has hypovolemia; thus
diagnosis often is made as the result of suspicion based on
an injury such as a penetrating chest wound.
Emergency department treatment of a patient with
cardiac tamponade is pericardiocentesis (Fig. 74.6). The
procedure is performed by inserting a 14- or a 16-gauge
catheter in the left subxyphoid position with the needle
aimed toward the posterior portion of the left shoulder.
Aspirating as little as 10 to 20 mL of blood can bring about
dramatic improvement in myocardial function; however,
frequent false-negative and false-positive results under
extreme circumstances may prompt a left anterior thoracotomy with direct pericardia! decompression.
Emergency thoracotomy is an option when a trauma
patient does not respond to resuscitation and is in cardiac
arrest. Other considerations for emergency thoracotomy
include initiating direct cardiac massage and controlling
massive hemothorax due to cardiac puncture or tears in the
thoracic aorta.
Myocardial contusion, another cause of cardiogenic
shock after trauma,. is caused by blunt injury, typically

1100

Section V: Trauma

injuries and the need for definitive surgical intervention. Valuable information regarding the patient's history must be collected, including the mechanism of
injury, preexisting medical problems, CWTent medications, known drug allergies, and when the patient last
ate. Routine objective studies also can be performed at
this time, including a complete blood cell count, chest
radiography, and urinai}'Bis. If drug overdose or alcohol
consumption is suspected, appropriate toxicologic studies can be performed. Hypotension warrants blood typing and cross-matching.

FiguN 74.6 Peric:ardiocantesis for acute cardiac tamp:made

perfonned Utrough the left subxyphoid approach.

when the chest hits a steering wheel. Phy!ical signs

include ecchymotic discoloration of the anterior chest
wall and flail chest. Severe myocardial contusion is
Wtusual, whereas blWlt chest trauma is common.
Marked myocardial contusion can be confirmed with
transthoracic or tran.sesophageal electrocardiography.
Wall motion, valvular dysfunction, and the presence of
pericardia! fluid or tamponade can be seen with echocardiography. Management is aimed at preventing fluid
overload while maintaining cardiac output and medically
suppressing ventricular arrhythmia With the increasing
frequency of trauma among elderly patient!, the possibility of an acute myocardial infarction, arrhythmia. or
congestive heart failure precipitating an accident must be
strongly considered (13).

Secondary Survey
1he secondary survey consists of a detailed physical
examination with the patient fully exposed. It is Widertaken once the lifesaving priorities of the primary survey have been addressed. 1he breadth and speed of this
examination depend in huge measure on the patient's

Head and Spine Injuries

.Altered mentation is the most frequent sign of injury to the
CNS and is presumed to be caused by injury Wltil proved
otherwise. Cervical spinal and spinal cord injuries are
common among patients with multiple injuries, and the
greatest concern is to avoid further injw:y to vital neurologic structures. Rigid immobilization of the cervical spine
is imperative until a complete set of spinal radiographs,
including cervical, thoracic. and lumbar spine radiographs,
has been obtained. 1he entire spine is palpated for tenderness and altered contour. For patients with definitive cervical spinal injuries, use of a rigid collar reinforced with
sandbags on either side and wide tape across the forehead
is mandatory (F'tg. 74.7).
Altered mental status can be caused by direct injw:y to
the cortex and brainstem, by increased intracranial pressure
(ICP), or by decreased cerebral perfusion. Whereas the fu:st
two conditions necessitate formal neurosurgical inter:vention, the changes in pressure and perfusion can be managed in the emergency department 1he tool used to assess
mental status is an abbreviated neurologic emmination to
define the Glasgow Coma Scale score (Thble 74.1). This
graded evaluation is performed to assess the functions ofeye
opening, verbal response, and motor response. A Glasgow
score less than 8 indicates serious head injury, although the
score can be artificially low if an endotracheal tube is in
place. Further neurologic assessment includes evaluation of
pupillaxy reflexes, deep tendon reflexes, and rectal sphincter tone. A serious head injw:y can have nonneurologic
signs such as hypoventilation and hypertension.
Emergency department treatment ofa patient with ahead
injw:y is aimed at minimizing cerebral edema and reducing
ICP. lhese goals are met by means of controlling the airway

Chapter 74: Principles of Trauma

GLASGOW COMA SCALE

Function
Eye Opening
Spontaneous
Verbal stimulus
Painful stimulus
None

Vetbal RE!$ponse
Oriented
Confused
Inappropriate
Incomprehensible sounds
No response
Intubated 1T
Best Motor Re5pon.se
Obey5 commands
Localizes painful stimulus
Withdraws from painful !rtimulus
Flexion response
Extensor response
No response
Score Range
Extubated
Intubated

Score
4
3

2
1

5
4
3

2
1

6
5

4
3

2
1
~15

3T-11T

to maintain acceptable oxygenation. Ventilation is adjusted

to maintain a ca:rbon dioxide level of about 35 mm Hg.
Patients with suspected cerebral trauma and a Glasgow
Coma Scale score less than 8 need continuous monitoring
of ICP. ICP is maintained at less than 20 mm Hg. Elevations
in ICP are managed by means of administering mannitol,
an osmotic diuretic. to reduce the amount of intracellular
water in the brain. Ventriculostomy can be used to monitor
ICP and can be therapeutic in that it allom cerebrospinal
fluid remaval to control ICP. Maintenance ofcerebral blood
flow, measured as a cerebral perfusion pressure (mean arterial pressure minus ICP) of70 mm Hg with the use offluids

1101

and vasopressoiS, is gaining increasing acceptance. There

is no role for the administration of steroids for the control
of cerebral trauma. Any patient who has changes in mental status after injw:y needs cranial computed tomography
(Cf) as part of the secondaty Slli'Vey (17).
The management of spinal cord injury with distal
deficits has changed over the last several years. Emphasis
remains on maintaining spinal immobilization to prevent
additional spinal cord injury. Recent research {18) has
found that administering steroids can play a role in minimizing neurologic deficits for patients with spinal cord
injuries. Administering methylprednisolone as a bolus of
30 mg/kg followed by a drip at 5.4 mg/kg each hour for
23 hours led to small improvement in neurologic function
among these patients when administered within 8 hours
of the injwy.
Once the neurologic system has been evaluated, the secondaJ:Y survey continues with assessment of the rest of the
head. The scalp can be a source of considerable blood loss,
and immediate suturing may be needed. Basilar skull fractures can manifest as mobility of the facial bones, hemetympanum, cerebral spinal fluid otonhea and rhinorrhea,
and periorbital and mastoid ecchymosis.

Nedc Injuries
All injuries to the neck are potentially life threatening
because numerous vital strucwres traverse this area. Neck
injuries are classified as blunt or penetrating. Blunt trauma
to the neck can cause cervical spinal injury, pharyngeal and
tracheal injuries, and carotid arteiy injwy. Penetrating neck
wounds are classified according to location (see Chapter
76). Zone I injuries are below the level of the clavicles,
Zone II injuries are between the clavicles and the angle of
the jaw, and Zone Ill injuries are above the angle of the
jaw (Fig. 74.8). Posterior injuries can damage the cer:vical
spine. Anterior and lateral wounds can injure the great vessels of the neck, the larynx. the trachea. and the esophagus as well as important nerves such as the vagus, phrenic.
hypoglossal, spinal accessory, and branchial plexus. High

Figure 74.8 Penetrating neck wounds are classified

according to location. Zone I injures are below the
level of Ute clavicles. Zone II injures are between the
clavicles and the angle of the jaw. Zone Ill injures are
above the angle of the jaw.

1102

Section V: Trauma

penetrating injuries (Zone ID) threaten the great vessels

and cranial nerves at the base of the skull; penetrating injuries at the base of the neck (Zone I) threaten the great vessels mting the thoiaX.
Clinical ez:amination of an injured neck involves careful airway assessment. including evaluation for hoaneness,
stridot dyspnea, and hemoptysis. Subcutaneous emphysema,. crepitus, and distorted laryngeal landmarka indicate
laryngotracheal injury. Dysphagia and chest pain are characteristic of esophageal injuries. Flexible lar:yngoscopy is an
excellent tool for aamining the hypopharynx and larynx
after neck injuries. It is rapid and easy to use and provides
an excellent way to evaluate the patency of the ait:way and
the function of the larynx. Flexible laryngoscopy also can
aid in diagnosing laryngeal fractures and wgal injuries. cr
of the neck also can help to delineate laryngt:al fractures.
When laryngeal or tracheal injury is apparent and airway compromise is imminent, tracheotomy is performed.
Cricothyrotomy is not used under such circumstances
because of the risk offurther injw:y to the larynx and upper
trachea. .Although it may be necessary to perform tracheotomy in the emexgency department, this procedure is
best done in the operating room, where proper instrumentation. optimal lighting, and appropriate personnel are
availabl~ especially when the patient has sustained blunt
laryngotracheal disruption. This injury usually is caused
by severe compression of the laryngotracheal complex
between the steering wheel and the vertebral column or
from "clothesline"' injury, such as catching the neck on a
baibed-wire fence while riding a snowmobile or a motorcycle. Under these circumstances, active airway management can be &aught with danger. Intubation may not be
feasibl~ and tracheotomy can cause retraction of the distal
trachea into the mediastinum.
Patients with penetrating neck injuries are at risk of airway obstruction. hemorrhag~ and injury to the cervical
spine. Important clinical signs include strid~ hoaneness,
subcutaneous emphysema,. expanding hematoma,. e:nemal
hemorrhage. hemoptysis, dysphagia, cranial nerve dy!function. and branchial plexus injw:y. Active airway intervention is important when there is evidence of airway distress.
It is best accomplished with nasotracheal or orotracheal
intubation. Bleeding in the oropharyngeal area may preclude intubation and necessitate emergency surgical airway
inteNention. which can cause great difficulty if there is
bleeding in the deeper layers of the neck. External hemorrhage is controlled with compression. and no effort is
made to gain hemostasis by means of blind damping.
lhere has been much controversy with regard to routine
exploration of penetrating neck injuries, not only as definitive treatment but also as a diagnostic technique. Some
authors advocate routine exploration of all injuries penetrating the platysma Others advocate selective exploration and observation based on preoperative arteriographic
:findings and on the presence or absence of symptoms that
suggest vasculru;. airway, and neurologic injw:y.

Most patients in stable condition with penetrating injuries

to the base of the neck (Zone I) are bestaamined by means of
arteriography, laryngoscopy, and esophagoscopy or a bari.um
swallow radiographic study. P.Uients in stable condition with
penetmtinginjuries abaretheangleofthemandible (Zone Ill)
are best examined with arteriography to exclude arotid or
vertebral artery injw:y. Patients with injuries between the angle
of the mandible and the base of the neck (Zone D) can be
examined by means of routine cz:plomtion or combinations
of arteriography, laryngoscopy, and esophageal evaluation if
the injury has penetrated the placysma Patients in unstable
condition with a~ ht'Jllorrhage need surgical exploration.
When a patient has marked neurologic deficits after
blunt neck trauma and the :findings of cr of the head are
normal, the possibility of blunt carotid injury with carotid
occlusion or dissection is considered and excluded with
arteriography. Management of these injuries involves anticoagulation with heparin or reconstruction, depending on
the nature of the injury.
Thoracic Injuries
Thoracic injuries are classified as blunt or penetrating.
Most blunt injuries are caused by motor vehicle accidents.
Penettating injuries typically are from violence with knives
or guns. The principal forms of life-threatening blunt chest
trauma are ftail chest, pulmonary contusion. tracheobronchial disruption, and tom thoracic aorta
Flail chest ocaJJS when part of the chest wall becomes
isolated owing to multiple fractures of the ribs or stf!mum
(Fig. 74.9). The sevmty is determined by the size of the ftail

Figure 74.9 Flail chclst.

Chapter 74: Principles of Trauma

segment, which moves paradoxically with inspiration and

thus reduces ventilatmy efficiency. Ventilation is further
compromised by the size of the underlying pulmonary contusion that invariably accompanies a severe flail chest If ventilation becomes inadequate, hypoxia and hypercapnia occur
and the patient needs intubation and ventilatoiY assistance.
Pulmonary contusion is a common finding in blunt chest
trauma. It often is associated with flail chest and hemopneumothorax and is common in multisystem trauma.
Pulmonary contusion causes alveolar edema and impairs
gas exchange. The primary sign of pulmonary contusion is
hypoxia. Initial management is adequate oxygenation and
avoidance of fluid overload, which can promote pulmonary
edema. If a patient has hypovolemia and pulmomuy contusio~ aggressive fluid resuscitation is indicated, regardless if
lung injury is present. Intubation and mechanical ventilation often are needed to support respiration.
Most intrathoracic blunt tracheobronchial injuries are
caused by compression of the trachea and bronchi between
the sternum and the vertebral column in motor vehicle accidents. The areas most commonly involved are the proximal
mainstem bronchi and the distal trachea. Common features
of this injury include pneumothorax. subcutaneous emphysema, and hemoptysis. Initial therapy often entails venting
the pneumothorax. Bronchoscopy is indicated for diagnosis.
Traumatic rupture of the thoracic aorta is the most common cause of immediate death after motor vehicle accidents. In 90% of cases, the aortic injury occurs beyond the
origin of the left subclavian artery at the level of the ligamentum arteriosum, where the descending aorta is relatively fixed. Motion between the more mobile aortic arch
and fixed descending aorta can cause aortic injury when
rapid deceleration is the mechanism. In about 10% to 20%
of cases, thoracic aorta rupture does not cause immediate death because intrathoracic hemorrhage is contained
by the aortic adventitia, and the patients can be saved if
the injury is rapidly recognized. Although arteriography
is the only definitive study for diagnosing this injury, the
first indication of an aortic tear usually is evidence of superior mediastinal widening on routine chest radiographs.
Clinical features, such as retrostemal or interscapular pain
from mediastinal blood dissection and hypertension from
sympathetic stimulation of the nerves around the aorta,. can
provide clues to the presence of aortic rupture. Early recognition and definitive surgical repair are crucial because the
rupture becomes complete in a high percentage of patients
within the first 24 to 48 hours after injury. The decision to
perform thoracic arteriography to exclude aortic disruption
is made early in the resuscitation and is based on findings
of mediastinal widening on the initial supine chest radiograph obtained in the emergency department
The injuries associated with penetrating thoracic
trauma-hemopneumothorax, tension pneumothorax,
and cardiac tamponade-are discussed earlier. After immediate management, a decision must be made regarding
surgical thoracotomy when there is persistent bleeding

1103

from a chest wound. Considerations include the volume of

the initial chest tube drainage, the rate of ongoing hemorrhage once the lung has been reexpanded, and the patient's
hemodynamic status.
Abdominal Injuries

Abdominal injuries are life threatening because the peritoneal cavity can harbor occult blood loss and fecal contamination. Unrecognized abdominal injury is a common
cause of death after trauma. and prompt recognition is
of primary importance in its prevention. Diagnosis can
be delayed by the silent nature of the injury, other lifethreatening problems, or an altered state of consciousness.
Examination of the abdomen begins at the level of the
nipples and extends to the pubic symphysis. The examination includes inspection, auscultation, percussion, and
palpation. Rectal examination is mandatory for assessment
of sphincter tone, pelvic crepitus, prostate position, and
hemorrhage. Although the absence or presence of bowel
sounds may not correlate well with the presence of injury,
other signs, such as abdominal tenderness, are highly suggestive of peritoneal inflammation and can indicate the
need for laparotomy.
Abdominal injuries are classified as blunt or penetrating. Blunt abdominal injuries usually are associated with
injury to solid organs, such as the liver, spleen, pancreas,
and kidneys. The most common finding among patients
with blunt abdominal trauma and solid organ injuries is
hemoperitoneum with shock. Trauma patients with persistent hypotension and possible blunt abdominal trauma
require a search for occult bleeding. This can be done expeditiously with focussed assessment for the sonographic
evaluation of the trauma patient (FAST) or diagnostic peritoneallavage (DPL). These studies can be done rapidly in
the trauma bay. FAST is an ultrasonographic examination
performed by the trauma surgeon or emergency room physician and can detect fluid in the peritoneal cavity (19). In
addition, the pericardia! sac can be evaluated. In hospitals without the expertise or equipment to perform FAST,
a DPL can be performed. Initial peritoneal aspiration of
more than 10 mL of blood is an indication for laparotomy.
Lavage is performed by means ofinstilling 15 mgfkg normal saline solution into the perito neal cavity and letting the
fluid drain out by means of gravity. When the total erythrocyte count in the lavage effluent exceeds 100,000/mL,
most patients have abnormal findings at laparotomy.
Abdominal cr is an excellent diagnostic study to
exclude intraperitoneal or retroperitoneal injury if the
patient is in hemodynamically stable condition. As experience with abdominal cr has increased, it has become dear
that many patients with minor liver and spleen injuries
with hemoperitoneum stop bleeding spontaneously and
never need abdominal exploration.
Patients with penetrating abdominal trauma and overt
signs of peritonitis or hypovolemia need surgical exploration; however, therapy is less dear-cut when the patient's

1104

Section V: Trauma

condition is hemodynamically stable or when signs of

peritonitis have yet to evolve. The common mechanisms of
penetrating trauma are gunshot wounds and stab wounds.
With gunshot wounds, laparotomy is indicated when
the missile penetrates the peritoneum. Plain abdominal
radiographs are obtained to outline the missile trajectory.
Broad-spectrum antibiotics are administered in anticipation of definitive surgical therapy.
Stab wounds of the abdomen can be managed selectively because the likelihood of visceral injury. even
with peritoneal violation, is inconsistent. The first diagnostic steps are to ascertain the depth of the injury and
to assess the integrity of the peritoneum. These steps are
best done by means of exploring the wound in the emergency department with the patient under local anesthesia.
Peritoneal lavage follows local exploration if there is an
indication that the anterior muscular fascia has been penetrated. Criteria for a positive peritoneal lavage result differ in blunt injuries from stab wounds. Although 100,000
erythrocytes per milliliter is the accepted positive result for
blunt injuries, an erythrocyte count of 5,000 to 10,000/mL
is accepted as a positive result in a stab wound and indicates that laparotomy is needed. Patients with positive
peritoneal lavage results need exploratory laparotomy.
Those with negative peritoneal lavage results can be admitted for observation.

Extremity Injuries
During the secondary survey, the arms and legs are examined carefully to assess perfusion, neurologic function,
deformity. and range of motion. Serious injuries include
fractures, dislocations, amputations, and compartment
syndromes. Life-threatening injuries involve massive blood
loss due to pelvic fractures, traumatic amputations, and
open femoral fractures. Pelvic fractures associated with
hypovolemia are stabilized with application of MAST. An
expanding hematoma or pulsatile. bright red bleeding
indicates acute arterial injury and is controlled with manual pressure.
Before it is assumed that bleeding is coming from a
pelvic fracture when the patient's condition is unstable.
it is necessary to exclude ongoing intrathoracic or intraabdominal hemorrhage. Supraumbilical DPL may be indicated to exclude an intra-abdominal source of hemorrhage
in these patients. In the care of patients with persistent
pelvic hemorrhage, angiography is indicated for diagnosis
and definitive management by means of embolization of
the bleeding vessels by interventional radiologists. A direct
surgical approach to the bleeding pelvis rarely is indicated.
Rectal and vaginal examinations are an important part
of the management of pelvic fractures. Patients with severe
pelvic fractures may have associated injuries to the vagina,
rectum, and urethra. A high-riding prostate or a positive
result of a heme test of stool can alert the clinician to this
possibility. Bladder rupture also is considered if a patient

has a pelvic fracture and hematuria. An abnormal result

of a prostate examination or blood at the urethral meatus
indicates urethral injury and is a contraindication to
insertion of a Foley catheter. Under this circumstance, retrograde urethrography is performed before a Foley catheter is placed.
Vascular injuries can be associated with penetrating
wounds, fractures, and joint dislocation. Signs are typically those of ischemia, and the patient has pain, pall01:.
paralysis, paresthesia, and pulselessness. Recognition is
important to preserve the extremity. and the diagnosis is
confirmed with arteriography. Knee dislocation is often
associated with popliteal artery injury and distal ischemia.
Popliteal artery angiography is usually recommended to
exclude injury if a patient has a knee dislocation.
Crush injuries to the lower leg and forearm can cause
compartment syndrome due to hemorrhage and edema
within recognized fascial planes. The patient typically
has a painful, pale extremity with decreased sensation
and pulse. The earliest sign of compartment syndrome
is the patient's report of paresthesia or sensory deficit in
the limb. Loss of peripheral pulses is a relatively late finding and often implies irreversible damage to the limb.
Compartment syndrome occurs most often with closed
fractures of the tibia and fibula. Emergency fasciotomy is
the appropriate therapy.
Traumatic amputation necessitates microsurgical reimplantation when possible. Bleeding from the proximal limb
is controlled with manual pressure. The amputated parts
must be kept in a moistened sterile towel and placed in
crushed ice until definitive therapy can be provided (11, 12).

Inhalation Injuries
Thermal injuries must be managed in an orderly way.
similar to that of all serious traumatic injuries. Inhalation
injuries occur in 3% to 20% of all bum patients. Most
inhalation injuries are caused by fires in closed spaces, but
the possibility of blunt injuries to the throat or abdomen.
as in blast injures or car accidents with fires, must be considered. An otolaryngologist may be asked to facilitate airway management for patients with inhalation injuries.
Although all types of trauma are suspect, specific types,
such as explosive bums and bums sustained in a confined
building, are associated with inhalation injury. Physical
signs of inhalation include a decreased level of consciousness, singed nasal hairs, carbon deposits in the oral cavity.
carbonaceous sputum, and the finding of inflammatory
changes in the supraglottic larynx at flexible laryngoscopy.
The glottic and supraglottic airway can sustain marked
edema from routine thermal trauma. The result is immediate or delayed airway obstruction. Patients with clear signs
of supraglottic inhalation injuries need early endotracheal
intubation with mechanical ventilation. The subglottic
airway often is protected from burns unless the patient is
exposed to superheated gas or steam. The vocal folds form

Chapter 74: Principles of Trauma

an anatomic barrier. In addition, reflex closure of the glottis also serves to protect the subglottis and trachea. Carbon
monoxide levels in the blood should be measured and
oxygen therapy should be given immediately. Hyperbaric
oxygen therapy is considered when a patient has marked
carbon monoxide poisoning (12).

Definitive Managem ent

Once the primary and secondary surveys have been completed, the patient has been adequately resuscitated, and
the patient's condition is judged to be stable, a plan for
definitive care is formulated. This plan begins with a ranking of the injuries in the order in which they are to be managed. If at any point the vital signs become unstable, the
primary and secondary surveys are repeated. If the instability is from an injury that warrants definitive surgical intervention, the patient is transferred to the operating room.
Patients who do not need further surgical intervention are
transferred to the intensive care unit or to a surgical floor
for further observation. Transfer errors include inadequate
managemen t of the airway, poorly secured intravenous
lines and drainage tubes, and inadequate patient monitoring. It is a tragedy to resuscitate a patient in the emergency
department successfully only to lose the patient on transfer
to the operating room.

ROLE OF THE OTOLAR YNGOLO GIST

Since the early 1970s, the responsibility of otolaryngologists as members of the trauma team has continued to
expand. In most institutions, otolaryngologists are viewed
as experts in managing the airway and are expected to perform difficult intubations and provide emergency surgical
airways. They are also being recognized for expertise in the
managemen t of maxillofacial trauma and penetrating injuries to the neck. Otolaryngologists often are called on to
assist in the immediate care of trauma victims in the emergency department
As valued members of the trauma team, otolaryngologists must continue to refine managemen t skills for
injuries associated with the specialty but also need to be
knowledgea ble about the general care of trauma patients.
Otolaryngol ogists need to understand the concepts of
the primary and secondary survey and be capable of
stabilizing the neck, securing the airway, placing chest
tubes, and starting intravenous lines. They also should
be able to perform the complete examination s needed
in the secondary survey and know how to interpret the
diagnostic procedures that must be performed as part
of the survey. To be fully integrated and recognized as
responsible members of the trauma team, otolaryngolo gists involved in the care of trauma patients should be
certified by the American College of Surgeons advanced
trauma life support course.

1105

The most fundamental neuroendocr ine reaction to

trauma is the release of catecholamines, which cause
vasoconstriction, increase cardiac rate, increase myocardial contractility and conductivity, and stimulate
gluconeogenesis.
The postinjury period is characterized by catabolism
with negative nitrogen balance, hyperglycemia, and
heat production, all of which reflect the reparative
processes.
The most important factor in the successful care of
trauma patients is the initial evaluation and resuscitation performed partly in the field and in the emergency department. Primary and secondary surveys
allow physicians to manage complex multisystem
problems. This treatment algorithm has four stepsprimary survey, resuscitation, secondary survey, and
definitive care.
The foremost emergency measure after trauma is
airway establishment. The primary risk during early
airway managemen t is movement of the neck when
there is an occult cervical spinal fracture. When the
airway is being controlled, it must be assumed that
such a fracture exists.
Correct positioning of the endotracheal tube can be
confirmed reliably by the presence of end-tidal carbon dioxide. If no aubon dioxide is detected, the
endotracheal tube is in the esophagus, and a new
attempt at intubation is made immediately.
In the trauma patient, continuous monitoring with
pulse oximetry is extremely helpful in determining
the adequacy of oxygenation and is used in the care
of all critically injured patients.
Techniques of surgical airway managemen t include
needle cricothyrotomy, standard cricothyrotomy,
tracheotomy, and percutaneou s tracheal ventilation.
Needle cricothyrotomy is the best procedure for children; surgical cricothyrotomy is preferred for adults.
Loss of respiratory drive among trauma patients
most commonly is caused by severe head trauma;
however, injuries to the chest wall and thoracic
structures can cause hypoventilation, which must be
recognized and rapidly treated.
Shock is the clinical manifestatio n of the inability of
the heart to maintain adequate circulation to vital
organs. The patient dies unless oxygenation and
perfusion are restored. The most common cause of
shock after trauma and hemorrhage is hypovolemia.
Treatment is rapid volume replacement with crystalloids, such as lactated Ringer solution or normal
saline solution through two 14--gauge catheters in
the anterubital fossa.

1106

Section V: Trauma

Cardiogenic shock is loss of circulatory perfusion

that occurs when the myocardium does not generate
sufficient blood flow for tissue oxygenation. Among
trauma patients, cardiogenic shock usually is precipitated by tension pneumothorax, cardiac tamponade,
or myocardial contusion. The presence of myocardial contusion is best confirmed with echocardiography. Among elderly trauma patients, the possibility
that acute myocardial infarction or anhythmia has
precipitated an accident must be considered.
In the care of patients with head trauma, ventilation
is adjusted to maintain a carbon dioxide level of
about 35 mm Hg. Patients with cerebral edema or
coma need continuous monitoring ofiCP. ICP must
be maintained at less than 20 mm Hg. Elevation
in ICP is managed with mannitol. Maintenance of
cerebral blood flow as measured by cerebral perfusion pressure is best accomplished with the use of
fluids and vasopressors.
In the care of patients with spinal cord injury,
administration of methylprednisolone as a bolus of
30 mg/kg followed by a drip at 5.4 mgfkg each hour
for 23 hours has been shown to lead to small but
important improvements in neurologic function if
administered within 8 hours of injury.
The decision to perform thoracic arteriography to
exclude aortic disruption must be made early in
resuscitation. The decision is based on findings of
mediastinal widening on the initial supine chest
radiograph obtained in the emergency department.
Unrecognized abdominal injury is a common cause
of death after trauma. Ultrasonography, when available, is the preferred step in the initial phase of
assessment and management. Peritoneal lavage is
an acceptable alternative. A total erythrocyte count
of 100,000/mL correlates with positive findings
at laparotomy after blunt abdominal trauma. For
patients with penetrating abdominal trauma, a total
erythrocyte count of 5,000 to 10,000/mL correlates
with positive findings at laparotomy.
Abdominal cr is an excellent diagnostic study to
exclude intraperineal and retroperineal injury if the
patient is in hemodynamically stable condition.
The extremity injury that poses the greatest risk to
life is a pelvic fracture resulting in massive blood
loss. The best initial management is application of
MASf followed by angiography.
The earliest sign of compartment syndrome is the
patient's report of paresthesia or sensory deficit in
the limb. Loss of peripheral pulse is a relatively
late finding and often implies irreversible damage
to the limb. Compartment syndrome occurs most
often with closed fractures of the tibia and fibula.
Amputated body parts must be kept in a moist and

sterile towel and placed in crushed ice until definitive reimplantation can be provided.
The physical signs of inhalation injury include a
decreased level of consciousness, burned nasal
hairs, carbon deposits in the o ral cavity, and inflammation of the supraglottic structures. Signs of this
type of injury are indications for early endotracheal
intubation and mechanical ventilation.
Definitive management follows the primary and
secondary surveys and begins with ranking of the
injuries in the order in which they are to be managed. If at any point the vital signs become unstable
once again, the primary and secondary surveys are
repeated. Transfer out of the emergency department
for definitive management can be a period of risk.
Transfer errors include inadequate management of
the airway, poorly secured intravenous lines and
drainage tubes, and inadequate patient monito ring.
To be fully integrated and recognized as responsible members of the trauma team, otolaryngologists involved in the care of trauma patients should
be certified by the American College of Surgeons
advanced trauma life support course.

REFERENCES
1. National Center for Injury Prevention and Control. Web-Based
Injury Prevention and Control. Web-Based Injury Statistics Query
and Reporting System (WISQARS). 2001. Available at: http://
www.cdc.gov/ncipc,fwisquars. Accessed November 13, 2004.
2. Bonnie RI. Fulco CE, Liverman cr. eds. &ducing the burden of
injwy: advancing f11'evention and treatment. Washington, DC:
National Academies Press, 1999.
3. Finkelstein E. Fiebelkorn I, Corso P. et al. Medical expenditures
attributable to injuries-United States, 2000. MMWR Morb
Mortal Wkly Rep 2004;52:1-9.
4. Doll L. Binder S. Injury prevention research at the centers for
disease control and prevention. Am J Public Health 2004;94(4):
522-524.
5. Dinh-Sarr TB, Sleet DA, Shults RA, et al. Reviews of evidence
regarding intervention to increase use of safety belts. Am J Prell
Med 2001;21(suppl4):48-65.
6. Thompson RS, Rivara FP. Thomson DC. A case-control study of
effectiveness of bicyle safety helmets. N Eng! J Med 1989;320:
1361-1367.
7. Shults RA, Elder Rw; Sleet DA, et al. Reviews of evidence regarding interventions to reduce alcohol-impaired driving. Am J Prell
Med 2001;21(4 Suppl):66-88.
8. Istre GR. Mallonee S. Smoke alanns and prevention of housefire-related deaths and injuries. We.st/ Med 2000;173(2):92-93.
9. Badar VJ, Lowry SF. Systemic response to injury and metabolic
support. In: Brunicardi FC, ed. Schwam:;'s principles of SUJXIl1JI,
9th ed. New York: McGraw-Hill, 2010:15-50.
10. Mullins RJ, Shock. electrolytes, and fluid. In: 'Ibwnsend CM Jr; et
al., eds. Sabistun's wrbook of surgery: the biologic basis ofmodem swgical practice, 18th ed. Philadelphia. PA: WB Saunders, 2008:55-67.
11. Hemmila MR. Wahl WL. Management of the injured patient. In:
Doherty GM. Way LW. eds. Cu1rent surgical diagnosis and treatment, 12th ed. Norwalk. CI': Appleton & Lange, 2006:207-244.
12. Eddy AC, Heimbach DM, Frame SB. Trauma and bums. In:
Lawrence PF, ed. Essentials of general suJXery, 2nd ed. Baltimore,
MD: Williams & Wilkins, 1992:145-165.

Chapter 74: Principles of Trauma

13. Zuckerbraun BS, Peitzman AB, BillarT. Shock. In: Brunicardi FC,
ed. Schwartz!s principles ofSU!!el}l, 9th ed. New York McGraw-HilL
2010:89-112.
14. Sritharan K. Thompson H. Understanding the metabolic
response to trauma. Br J Hosp Med (Lond) 2009;70(10):
M156-M158.
15. Boldt J, Fluid choice fur resusciatation of the trauma patient: a
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1107

16. Croaby ET. Airway management in adults after cervical spine

trauma. Anesthesiology 2006;1104(6):1293-1318.
17. Bullock R. et al. Guidelines for lhe management of severe head injury.
Brain 'Itauma Foundation, 2007.
18. Hurlbert RJ. The role of steroids in arute spinal oord injury: an
evidence-based analysis. Spine 2001;26(24 Suppl):S39-S46.
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Scott SluJdfar

William W. Shockley

Soft tissue injuries involving the face, head, and neck are
becoming more frequent, and the experienced otolaryngologist is commonly the designated surgeon chosen to
make a timely assessment and repair. The management
of facial soft tissue injuries present challenges both from
a functional and aesthetic perspective. Injuries to the face
can affect speech, vision, alimentation, and facial expression. The resulting facial scars and deformities also can be
associated with a host of psychosocial issues. This chapter is devoted to the initial evaluation, classification, and
early management of facial wounds. We also provide specific anatomical considerations for different anatomic sites
with respect to facial soft tissue injury management and
care.

ETIOLOGY AND MECHANISM OF

INJURY
The leading causes of facial soft tissue injuries are assault,
motor vehicle accidents, work-related injuries, sport injuries, animal and human bites, as well as burns. In addition, there has been a surge in the literature highlighting
injuries encountered from the battlefield (1). Details
into whether protective measures were in place, such as
helmets, seat belts, or air bags, can guide the evaluation.
Injuries sustained despite these measures calls one's attention to the force behind the injury and need for further
workup.

EVALUATION
Patients with serious or life-threatening injuries are first
assessed in the emergency room, or trauma bay when
available. Advanced Trauma Life Support guidelines are
followed where airway, breathing, circulation, disability, and exposure (ABCDE) take precedence. In the critically ill patient, stabilization will proceed in a standard

1108

fashion with the insertion of two large-bore intravenous

lines. Acute hemorrhage from the head and neck region is
addressed at this time. An airway is established if deemed
necessary. Any oral or pharyngeal hemorrhage leading to
inability to protect the airway calls for airway intervention, all while maintaining cervical spine precautions. In
this setting, 3% to 10% of facial injuries with fractures have
concomitant c-spine injuries (2,3). Although facial injuries
can bleed profusely, they can distract health care providers
from other more immediately threatening injuries. Often
a moist gauze and pressure dressing can be applied to
facial wounds if other injuries, such as chest or abdominal
trauma, necessitate urgent treatment
A thorough history, if obtainable, is necessary when
a patient presents with a traumatic injury. Knowledge of
the patient's underlying comorbidities and past medical history is especially important in those patients with
compromised host defenses as in patients with diabetes,
immunosuppression, chronic corticosteroid use, malnutrition, and obesity.
Allergies to medications including local anesthetics, general anesthetics, and antibiotics should be documented. Social history regarding smoking, ethanol, and
illicit drug use should also be obtained. In most cases
of major trauma, serum alcohol levels and a drug screen
should be checked as the presence of cocaine or amphetamines may delay elective operative intervention; these
interactions with general anesthesia are known to increase
cardiac risks. Tetanus history should also be noted at this
time, with appropriate treatment based on the patient's
history (see section on "Tetanus).
A complete head and neck examination should be performed with final attention focused on the injured site.
A detailed description of the wound in terms of wound
classification, location, depth, length, and condition of
wound edges should all be assessed and documented.
Cranial nerve examination is performed to identify any

Chapter 75: Management of Soft Tissue Injuries of the Face

deficits. Next, evaluate for deep tissue injury (clear fluids

leaking indicative of cerebral spinal fluid [CSF], salivary, or
lacrimal injury) ( 4) as well as presence of fractures or foreign bodies (gravel, wood, broken or loose teeth). When
possible, photo documentation should be performed for
medical and legal reasons.
Prior to extensive examination and wound preparation,
appropriate anesthesia and analgesia should be provided
for patient comfort. The authors seldom use sedation, outside of the pediatric population. Imaging studies pertinent
to the head and neck region including plain films and
computed tomographic (Cf) studies should be obtained
when there is concern for facial fractures, missing teeth, or
foreign bodies. Noncontrast high-resolution CT imaging is
the preferred imaging modality to evaluate facial fractures,
while contrasted cr angiography is indicated for identification and delineation of a vascular injury as seen in
penetrating neck injuries (see Penetrating Head and Neck
Injury chapter). Once the patient has been stabilized, the
involved physicians should prioritize further workup, management, and surgical repairs. Depending on the nature of
the injuries, appropriate consultations should be obtained.

WOUND CLASSIFICATION

1109

care and observation, assuming there are no functional or

airway issues. Needle aspiration can be undertaken after
liquefaction of the clot, usually around 10 days post injury.
If hematomas occur in the tongue, floor of mouth, or neck
one must consider the potential for airway compromise. In
addition, underlying vascular injuries may be suspected.

Avulsion Injuries
Avulsion injuries result from the shearing or tearing of tissues. This leads to full-thiclmess cutaneous injury sometimes associated with loss of the involved tissue segment.
Avulsion injuries may be associated with subcutaneous,
cartilaginous, or bony structures. Avulsion injuries usually arise from high-velocity activities or exposures such
as motor vehicle collisions, blasts, and assaults, resulting
in shearing of tissues. On occasion, microsurgical techniques will be required for reattachment of avulsed tissues. Conservative trimming of nonviable tissue margins
may be necessary; however, tissue-sparing management is
preferred with frequent checks to confirm tissue viability.
If there are concerns over viability, steps should be taken
to optimize tissue vascularity, such as suture removal or
wound drainage (5). Specific considerations with respect
to management are discussed under each anatomical site.

Abrasions
Classifying wounds on assessment aids in sorting and developing a treatment algorithm. Wounds are most commonly
classified by depth, which is influenced by the mechanism.
When the epidermis and partial thickness dermis has been
lost, secondary to scraping the skin, this is classified as an
abrasion. For these injuries, the critical steps in management include irrigation and cleansing with meticulous
removal of any embedded dirt and debris. Once the wound
is fully clean, topical ointment is sufficient treatment. The
patient is instructed to keep the wound clean and dressed.
In most circumstances, a topical antibiotic ointment is
both practical and effective. Maintaining a moist environment without crusting helps promote faster reepithelialization from the remaining undisturbed skin appendages.
Avoidance of direct sun exposure is recommended as this
can cause sldn pigmentation at the site of injury, which
is most often temporary. Sun avoidance and protection
should be mandatory for a minimum of 6 months.

Contusions/Hematomas
Contusions are usually from blunt force trauma without
breech of the overlying sldn. Disruption of the small capillaries and vessels leads to swelling and ecchymosis. These
changes usually resolve over time without intervention.
Expectant management is usually sufficient with head elevation and ice packs. Soft tissue hematomas result in marked
swelling and can sometimes organize into a localized
hematoma. In most cases, all that is needed is supportive

Lacerations
Lacerations typically occur from impact or sharp objects
resulting in a cutting of the sldn as opposed to the tearing forces that result in avulsion injuries. lacerations can
be further categorized as linear, tangential, or stellate and
are many times jagged with macerated edges. The majority of facial soft tissue injuries fall under this category and
the tenants of closure and management are discussed in
greater detail throughout the chapter.

Puncture/Penetrating
Wounds that puncture the skin are classified as puncture
wounds. Those that enter and exit the sldn such as a knife
or bullet are known as penetrating wounds. Many times,
the underlying damage is more severe than the visible
portion of the wound and caution should be exercised in
assessing the patient or probing of the wound. The basic
principles of acute trauma care apply. Penetrating wounds
of the neck can be stratified into a level I to III classification
system. Please refer to Chapter 76 for further discussion
and management strategies.

Crush Injuries
Prolonged or excessive force placed on any anatomical location can lead to a crush injury. Luckily. the face
is seldom the site involved with isolated crush injuries.
However when segments of the face, head, and neck are

1110

Section V: Trauma

involved disastrous consequences may ocrur. Devitalized

tissue is frequently present due to small blood vessel injury
leading to necrosis and poor wound healing. Management
includes conservative trimming of nonviable tissue margins. Hyperbaric oxygen treatments have been shown to be
beneficial for hypoxic wounds in limb crush injuries, but
no randomized controlled trials have been performed that
provide useful guidelines for facial soft tissue injuries ( 6).

WOUND MANAGEMENT
General Considerations
Regardless of whether the injury is an abrasion, avulsion,
or laceration, the initial management is the same. Keeping
the wound moist with sterile saline-soaked gauze is recommended. Most wounds can be examined and repaired
in the emergency department trauma bay or exam room.
Exceptions include those injuries with underlying fractures, nerve, salivary, or lacrimal duct injuries, which will
require more complex techniques for repair. Additionally,
the pediatric population will often require conscious sedation or a general anesthetic for appropriate examination
and closure, depending on the injury. patient's age. and
level of cooperation.
Before repair, and many times before a thorough examination, local anesthesia is administered. Once appropriate anesthesia has been achieved, the surgeon can proceed
with tissue manipulation and attention should be turned
to systematic cleansing of the tissues using sterile normal
saline. Various methods can be employed to accomplish
removal of foreign debris and bacteria. Whether using a
bulb syringe. intravenous catheter on a syringe, or pulsatile irrigator, the goal is to decrease the wound bacterial
load. The presence of a wound inoculum of lOS bacteria
per gram of tissue has been shown to increase the risk of
wound infection. Three to five hours are generally needed
for bacterial proliferation to reach this inoculum in a clean
wound, and after 8 hours the bacterial load increases exponentially (7). Others have described using tap water (8) or
forgoing any irrigation in the setting of a clean, noncontaminated, nonbite wound to the face and scalp and did
not observe an increased rate of infection (9). The authors
still advocate wound irrigation with sterile normal saline,
as an inexpensive. effective. and noninvasive measure ( 4).
All dirt. debris, and foreign material must be carefully
and thoroughly removed to avoid the risk of infection or
traumatic tattoos. If irrigation techniques are not sufficient,
then a scrub or wire brush may be used to remove all material, paying careful attention as to not further damage the
delicate tissues or devitalize any partially avulsed flaps.
Solvents used to dissolve materials such as tar are only
used if absolutely necessary. Wound exploration and dissection may be needed to remove larger pieces of foreign
material. Wound debridement of any nonviable soft tissue
is performed with removal of necrotic tissue at the initial

encounter and subsequent encounters. If there is a question

of tissue viability. Futran advocates retaining the tissue and
allowing a 24- to 72-hour window for final declaration (10).
For large open wounds, the use of negative pressure
wound therapy (NPWT) can be utilized in those patients
awaiting definitive therapy. This modality allows promotion of granulation tissue through increased blood flow
to the wound, cellular proliferation from mechanical
stress placed on the cells at the wound surface, as well as
the removal of factors that inhibit wound healing. while
avoiding painful dressing changes (11). Contraindications
to NPWf related to soft tissue trauma are few, and include
fragile skin, ischemic tissue. and the presence of infection
( 11). Contours of the face. nose. lips, and ears can make
this technique difficult to apply in many cases.

Timing of Repair
The proper sequencing and staging of surgical care of facial
trauma patients is important in decreasing postoperative
complications and obtaining optimal results (5). Based on
the wound classification and extent, decisions are made as
to whether the injury is amenable to repair in the emergency room versus the operating room. Often patients will
be prioritized based on other injuries.
Although the timing of repair has been controversial over the course of the past 20 years, the paradigm
has shifted to immediate definitive repair after irrigation
and initial meticulous debridement of devitalized tissue.
Hochberg et al. argue that the best period for primary
repair is within 8 hours of the injury. Tissues are less vulnerable to infection, and wound healing is at its optimum
during that time, although this is also dependent on the
etiology, the patient's health, and the type ofinjury (12).
In patients with life-threatening injuries such as intracranial, cervical spine, and severe abdominal or thoracic injuries, surgical closure can be delayed. In those patients with
contaminated wounds, delayed repair is preferred due to
increased risk of infection. Local wound care and secondary
healing can be considered in grossly contaminated wounds
as well as those with tissue loss. Allowing wound contracture to ocrur may minimize the ultimate defect Delayed dosure is reserved for grossly contaminated wounds, selected
animal bites, infected wounds, and wounds greater than
24 hours old. 1Ieating with antibiotics and local wound
care for approximately 3 to 5 days has been shown to yield
the lowest bacterial counts at 96 hours after the injury. optimizing healing following delayed closure (7, 13).

Anesthesia
Local Anesthesia
Local anesthesia is usually sufficient to repair most facial
lacerations in adults and children. The choice of local
anesthetic depends on the length of procedure as well as
any known allergies or side effects noted by the patient.

Chapter 75: Management of Soft Tissue Injuries of tite Face

Lidocaine (1%) with 1:100,000 dilution of epinephrine
provides a dense block with appropriate time to dose most
lacerations. 1he epinephrine acts as a wsoc::onstrictot which
prolongs the anesthetic:: effects of lidocaine and provides
hemostasis. In the authors' experience, infiltration of lidocaine with epinephrine has been without consequence in
end arterial areas such as the nose and ear, and feel there
is no literature to substantiate its prohibition. 1he only
ew!ption would be its use in tissues, which appear to have a
tenuous blood supply. Dosing limitations should be closely
monitored in children and polytrauma patients, especially
if multiple teams are using local anesthetics. The maximum
recommended dose is 4.5 mg/kg for lidocaine and 7 mg/kg
for lidocaine with epinephrine (13, 14). The pain associated
with the injection of the local anesthetic can be minimized
and is influenced by temperature, pH, number of injections,
rapidity of injection, and size of needle (15). Warming the
anesthetic solution to body temperature, as well as achieving a more alkaline pH with the addition of1 milliliter (mL)
ofsodium biGUbonate to 9 mLoflidocaine (1:10 dilution),
should attenuate the pain of injection. Additionally, inserting the needle through the wound instead of penetrating
the skin, as well as injecting slowly through a 27 or 30 gauge
needle, will aid in lessening discomfort.
In the case of children, or those intolerant to local injections, topical anesthetics are available and can be used as
an alternative or adjunctive method of local anesthetic
administration. Several topical anesthetics are available and
are generally a combination of tetracaine, adrenaline, and
cocaine (orTAC); a combination of lidocaine, epinephrine,
and tetracaine (or LEI'); or a combination of 2.5% lidocaine
and 2.5% prilocaine (16). Application of topical anesthetics as an adjunct prior to needle infiltration may reduce the
pain of infiltration and can sometimes be used solely for
small superficial lacerations. Bear in mind that these must
be applied and left in place with an occlusive dressing for
30 to GO minutes or more for a pronounced effect.

Regional Anesthetics
Local infiltration of anesthetic suffices for most wounds
although regional nerve bloc::b may also be appropriate
in some settings. Nerve blocks of the ophthalmic division of the trigeminal nerve (supraorbital, supratrochlear,
infratrochlear) are performed with an injection along the
supraorbital rim from lateral to medial, while stretching
the eyebrow laterally. 1his can be used for scalp, upper eyelid. nose, and with the addition of auriculotemporal and
zygomatic branch blockade, the temporal region can also
be anesthetized. Ane:sth.e:sia of the lower eyelid, cheek. nose,
and upper lip through blockade of the infraorbital nerve
aids in closure of lacerations in these areas. Nasal blockade
can be more easily performed with appropriate regional
bloc::b and topical anesthetics. Lidocaine or cocaine can
be applied to the nasal mucosa by means of cotton tip
applicaton or pledgets, while the lower lip and chin can be
blocked through the use of mental nerve bloc::b (15).

1111

Figure 75.1 Regional block technique providing anesthesia to the

entire ear, exc:!udlng the concha and EAC. "X' Is the point of Initial
needle Insertion. Numbers 1-4 deoote the sequene of InJections.
Complete regional blockade of the ear is possible with
the exception of the concha and medial sw:face of the tragus which require direct injection if necessaJ:Y. Prior to injection, a cotton ball should be placed in the extmlal meatus
to block any blood from entering the extmlal auditory canal
(EAC). Using a c::iraJmferential approach, a single inferior
injection aimed anterior superi.or in the auric::ulotemporal
distribution is performed. This is followed by a postauriOJiar
injection directed from inferior to superior through the same
injection site, without removing the needle below the lobule.
Once anesthesia has set in a second pain-free needle stick can
be performed superiorly into the posterior auriOJiar area following the postauric::ular sulcus while avoiding the postaurirular artery. 1he final block is placed superior to the root of
the helix. from a posterior to anterior approach (Fig. 75.1).

Tetanus
Tetanus vaccination histoty is an important feature of any
trauma patient. Wounds can be divided into tetanus-prone
venus those that are not Tetanus-prone wounds include
those greater than 6 bows old stellate lacerations, avulsion injuries, wounds deeper than 1 em, and those with a
mechanism of injury from a missile, crush. burn, or frostbite. 1hose wounds presenting with signs of infection, containing dein.ner:vated or devitalized tissue or contaminants
such as dirt,. soil. feces, or saliva are also at high risk {7). If
both tetanus immune globulin and tetanus-diphtheria toxoid are given, they need to be given in different syringes and
at separate sites (7, 16). Dosing is beyond the scope of this
chapter but recommendations from the Centen for Disease
Control and Prevention (CDC) are shown in Thble 75.1.

Antibiotics
According to the guidelines distributed by the American
Academy of Otolaryngology-Head and Neck Surgery,
the use of prophylactic:: antibiotics are recommended

1112

Section V: Trauma

tETANUS PROPHYLAXIS IN WOUND MANAGEMENT

Recommendations for Tetanus Prophylaxis

NontetaniO-Prone Wounds

Tetanus-Prone Wounds

History of tetBnus lmmunlzlltlon

Td

Yes

TIG
No

Td
Yes

llG

<3 doses or uncertain doses

If 3 doses or greater and:
l.a5t dose within 5 y
l.a5t dose within 5-10 y
Last dose> 10 y

No
No
No

No

Ye$

No
No
No

No
No

Yes

Yes

Yes

Recommendations are based upon the CDC, Department of Health and Human Services Center for Disease Control and Prevention (WNW. c:dc.gov/
vaccines!)

Td, Tetanus diphtheria toxoid; TIG. Tetanus immunoglobulin.

for traumatized or contaminated wounds, incisions or

wounds crossing mucosal barriers, patients with prosthetic
devices, and patients with compromised host defenses
(13). Other facton that must be considered include the
mechanism of injucy and the time of presentation, with
those patients presenting with wounds greater than 24
hours from the incident clearly having a higher bacterial inoculum and likelihood of infection. Other wounds
such as compound fractures of the mandible or maxilla
with mucosal breech, contaminated wounds, or injuries
that occurred under water deserve prophylactic antibiotic
treatment as well ( 17). No literature exists to support routine prophylactic antibiotic usage in soft tissue injuries
to the face, so the authors follow the guidelines outlined
above
Oral penicillins are the antibiotics of choice. although
in penicillin-allergic patients use of dindamydn or cephalexin should be considered. Fluoroquinolones are suitable
for pseudomonal coverage in the case of underwater injucy.
In general 5 to 7 days is sufficient for prophylactic antibiotics. Grossly infected wounds are given therapeutic treatment with 48 hours of intravenous antibiotics, followed
by a total 10 to 14 days of the oral equiwlent. The pharmacology and microbiology of bite and bum wounds are
discussed separately.

ed~ is ofutmoat importance The use of skin boob is preferred in handling these damaged tissues as to avoid further
crushing of the wound edges. Even with meticulous closure
of complex lacerations, it is important to communiate to
the patient and family that scar revision may be necessacy.

Soft Tissue Principles of Closure

The aim ofsuture techniques in facial injuries is to achieve
a tension-free closure with appropriate and accurate tissue approximation. When applicable. closure along the
relaxed skin tension lines and abiding by the facial aesthetic units, can aid in making a scar more inconspicuous
(Fig. 75.2). The amountofunderminingnecessarypriorto
closure varies with the degree of tension anticipated with
the closure. A minimum number of nonreactive sutures
should be used for the deep layer. Although meticulous
closure may provide better tissue alignment excess deep
sutures may lead to a foreign body reaction. Too many
skin sutures may compromise blood supply to the wound

LACERATION REPAIR
When dosing facial wounds the inherent bond between
function and aesthetics cannot be overemphasized. The
surgeon's closure has bearing not only on societal cues, but
also in the patient's evayday functions of communiation,
breathing, alimentation, and display of emotions. This
must also be considered when preparing and debriding
the wound as distortion of contiguous structures can occur
with overaggressive debridement or skin advancement.
Complex or stellate wounds can sometimes be excised or
converted to simple lacerations which can then be dosed
primarily. Deliate and attaumatic handling of the tissue

Figure 75.2 A:. The relaxed skin tension lines

(RSn) should be
used In dosure design and lndslon planning. B: Depletion of the
fadal aesthetic units, highlighting the Importance of separate
reconstruction for each unit. F, forehead: T, temple: z. zygomatic;
M, mandibular; C. chin: I._ lower llp; U. uppc~r lip: N, nasal; I, Infraorbital; P. periorbital; Ne, neck: E, ear.

Chapter 75: Management of Soft Tissue Injuries of tite Face

resulting in local necrosis, most notably at the end oxgan

sites of the nose, eat or avulsed segments with a tenuous
blood supply (5).
Suture selection is based on several factors including
the depth of the injury, the extent of skin loss, the anatomic structures involved, and surgeon preference (18).
Generally, a braided or monofilament deep absorbable
suture is used with the lmot inverted to take tension offthe
wound and provide appropriate reapproximation without undue strangulation or tension. Some authors, especially in the setting of contaminated or bite wounds, prefer
minimally reactive monofilament sutures {e.g., polydiaxanone) over more reactive, braided sutures (e.g., polyglactin) for deep closure. The theoretical increased risk of
infection due to bacteria becoming embedded within the
braids as well as these sutures eliciting increased tissue
inflammation make monofilament absorbable preferred
by some authors (19).
The subcuticular or dermal suture provides wound
edge eversion and depth equality at the level of the skin
for a smooth cosmetic result. The epidermal layer closure has multiple possible techniques (running, interrupted, locking) and options including sutures, staples,
tapes, and liquid adhesives. Whether one uses a fine
nonabso:rbable (e.g., polypropylene) versus an abso:rbable suture (poliglecaprone 25 or fast abso:rbing gut) will
depend on the surgeon's preference, the likelihood of
the patient returning for follow-up, and whether a child
will cooperate with suture removal in clinic. Parell and
Becker noted no difference in long-term cosmetic results
of repairs with permanent versus absorbable sutures and
thus preferred abso:rbable sutures. The advantages were
that the sutures do not necessitate removal, thereby saving the surgeon time while lessening patient anxiety and
discomfort (20). Others have investigated tissue adhesives as an alternative to suture closure as means of saving time and offering greater convenience and comfort to

1113

the patient, especially in the pediatric population. Their

usefulness in the management of simple lacerations is
well accepted; however, they are less useful in complex
lacerations, have low tensile strength, and cannot be
used around moist mucous membrane due to premature
adhesive dissolution and release (21). Graphic representation of various suturing techniques is depicted in
Figures 75.3 and 75.4.

Postoperative Care
The importance of wound care should be stressed to
patients and families. The wound should be cleansed twice
daily using half strength hydrogen peroxide to prevent
crusting. A topical antibiotic ointment should be applied
after each cleaning. Since 7% to 13% of patients develop
atopic dermatitis associated with neomycin-containing
ointments, we recommend avoiding ointments containing
neomycin (22). Alternative ointments include bacitracin,
mupirocin, or those not containing an antibiotic such as
petroleum ointment or water-based ointments such as
Aquaphor (Beiersdorf AG, Hambwg, Germany). Sutures
on the face are generally removed in S to 7 dayJ following
repair.
Once the sutures are removed meticulous care should
be taken to avoid sun exposure. The use of broad spectrum lN-A and lN-B sun block with an sun protection
factor (SPF) greater than 45 is recommended for a minimum of 6 months to 1 year to prevent hypcrpigmentation
of the scar.
Inttaoral and intranasal sutures are usually absorbable
and these do not require removal. Antibacterial mouthwash such as chlorhexidine gluconate 0.12% is used three
times daily after meals for 1 week for inttaorallacerations.
lhe use of saline nasal rinses can be advised with avoidance of nasal manipulation or nose blowing in the setting
of nasal injuries.

Figure 75.3 Suturing principles for fadal

wounds. 14:. Inverted deep sutures reapproxl
mllt8 the wound Qdges, Qlfmlnllt8 dead spaa~,
and Juxtapose similar tlssi.KI layQrs. 1: Enrslon
of surface by well-placed sutuRas.

1114

Section V: Trauma

Figure 75.4 Suturing wchniques.

A:. Simple Interrupted. 1: Subcuticular
running. C: Vertical mattress. D: Simple
running. E: Running loc:k.Cid.

Simple
running

Drains
1he use of drains in acute facial ttauma is not routine but
may be advisable in wounds with atensive dead space
or following closure after evacuation of a hematoma.
A simple latex (e.g., Penrose) drain may be used to facilitate
drainage and inhibit reaccumulation. In areas with a large
dead space closed suction drains may be more appropriate.

Running
locked

lhe scalp is a highly vasrular region. The presence of a

rich network of vessels contributes to the profuse bleeding seen in scalp injuries, many times out of proportion to
the wound size. Direct pressure is necessary and sufficient

INJURIES BY ANATOMICAL LOCATION

Scalp
Injuries to the scalp are oftm present as gaping lacerations or
avulsions. 1he scalp is made up of:five distinct tissue planes
easily remembered by the mnemonic SCALP: S (skin), C
(subrutaneous tissue), A (galea aponeurotic layer), L (loose
areolar tissue), and P (pericranium) (Fig. 75.5). The layaed
makeup of the scalp make scalp avulsion injuries more frequent. with each layer providing a plane for dissection (23).
The vessels, lymphatics, and nf!J'\'lS course through 1he subcutaneous layer just superficial to the galea. while the loose
areolar tissue or subgaleal plane allows for scalp mobility.
As such,. scalp avulsions routinely occur through 1his laya;.
thereby leaving pericranium intact, which is an important
anatomic landmark that must be distinguished at time of
closure and reconstruction (23).

Figure 75.5 Five layers of the scalp: A skin: B, subcutaneous

tissue; C, galea aponeurosis: D, loose connective tissue: E, pericra
nium; F, calvarium (skull).

Chapter 75: Management of Soft Tissue Injuries of the Face

to temporize bleeding until further examination can be

undertaken. Injection of lidocaine with epinephrine into
the wound edges can help in temporizing bleeding as well.
When necessary full-thickness sutures can be placed to aid
in hemostasis.

Evaluation
Physical examination should proceed in a systematic
fashion with specific attention turned to the neurological
examination. Underlying skull fractures or associated intracranial processes must be considered. Particular attention
should be paid to the present hair distribution and hairline.
Wound closure should preserve these landmarks whenever
possible. Small areas of alopecia may be managed by wide
scar excision or hair transplantation in the future (24).

Closure
Wound preparation should be performed with copious irrigation, and undermining should proceed in the subaponeurotic plane. The scalp is known fori ts inelasticity, and moving
adjacent tissue for wounds greater than 3 em in size can pose
great difficulty. Some authors recommend galeal incisions
placed parallel to the laceration in hopes of recruiting an
additional 1 to 1.5 em of tissue and help decrease wound
tension during closure. This maneuver requires clinical judgment and experience and is almost never performed by the
authors. This strategy is at the expense of tensile strength and
vascularity, limiting its use in larger defects (24).
For moderate defects of 2 to 2.5 em in size,. Leedy et
al. (23) recommend use of V-Y flaps, V-Y-S flaps, subcutaneous pedicled flaps, or rotation advancement flaps. For
large defects with intact pericranium, options include use
of split-thickness skin grafts and secondary tissue expanders as well as flap reconstruction (23). Ifthepericranium is
intact the authors usually allow healing by second intention, thus allowing wound contraction to make the ultimate defect smaller. Reconstructive maneuvers mentioned
above are seldom employed at the initial repair.
If the pericranium is not intact, but the surrounding
scalp is viable,. rotation or other scalp flaps can be used to
fill the defect, with skin grafts or primary closure used at
the donor-site defect. Large defects without pericranium
can be treated with open wound care and complex reconstruction techniques such as rotation-advancement flaps or
free tissue transfer can be performed in a delayed fashion.
Total avulsion or near-total avulsion injuries are best
managed by microvascular reanastomosis and replantation
if the scalp tissue is viable and available. If this option is
not available,. the authors would typically treat the open
wound and then decide upon a strategy that might include
a STSG versus flap reconstruction. Leedy et al. ( 23) feel
that free tissue transfer is the best option such as a free
latissimus-serratus flap.
The use of 4-0 running locking nonabsorbable suture is
advocated for appropriate hemostasis and wound closure at
the level of the galea and dennis. Cosmetic results following

1115

skin closure have been shown to be equivalent with the use

of staples as opposed to sutures, in the pediatric population. Additionally, benefits from time savings, costs, and
decreased wound closure times were noted (25). One must
consider the restrictions in imaging with the use of stainless
steel staples if MRI imaging is anticipated in the immediate perioperative period. If satisfactory primary closure has
been obtained the authors allow gentle hair washing after
48 hours with mild baby shampoo. Whether staples or
sutures are used removal is typically at 7 to 10 days.

Complications
Specific to this area, complications include sensory deficits,
hematoma formation, scar deformity, and alopecia.

Forehead. Temple. Brow

The area of the forehead, temple,. and brow are anatomically linked, with features of significant esthetic importance. Damage to the neuromuscular structures that lie
within these regions can leave a patient with significant
functional deformities, including forehead paralysis and
brow ptosis. Resulting scars may be associated with traction on the eyelid resulting in visual impairment and
deformity. The unique layers of the temporal region must
be examined closely and are depicted in Figure 75.6, with
attention to the neurovascular structures within the various
layers. The superficial temporal fascia (STF) is contiguous
with the superficial muscular aponeurotic system (SMAS)
inferiorly and the galea superiorly. The temporal branch of
the facial nerve courses within the STF above the zygomatic
arch anterior to the superficial temporal vessels. By connecting a point 0.5 em inferior to the tragus to a point 1.5
em lateral to the superior brow, its course can be estimated.

Evaluation
Examination should document any sensory or motor
deficits. Palpation of the supraorbital ridges should be
performed observing any bony step offs concerning for
underlying fracture. It is important to assess for frontal
sinus fractures. CSF leak may occur with posterior table
involvement and may be visible in the wound. Epidural or
subdural hematomas can result from injuries in the temporal region, whereas temporal bone fractures can be associated with hearing loss or facial nerve paralysis.

Closure
Often there is ample adjacent tissue to move; however,
the position of important structures must be maintained.
Forward or lateral movements of the hairline or eyelid,
respectively, should be avoided. The contralateral brow can
be used as a guide to align the involved brow. The brow
should not be shaved as this is a critical landmark The
brow margins should be identified and the direction of hair
growth used for proper alignment. Other considerations
are the involvement of the temporal branch of the facial

1116

Section V: Trauma

Tempew parietal
fascia (superficial
temporal fascia)

Subaponeurotic plane
Temporal fat pad --if-+if++Anterior branch of
superficial temporal a.
Temporal branch of
facial n.
Superior extension
of buccal fat pad
Zygomatic arch
Temporalis m.---4---*-+-----\~-

Parotid duct ----4--it~

Buccal branch of ----t-~
facial n.

Figure 75.6 The unique anatomy of the temporal n.glon with attention directed at the STF and
the Intimate relationship with the temporal branch of the fadal nerve.

nerve, and caution should be ex.e:rcised with deep closure in

the pathway of this ne:rve, such as aver the zygomatic arch.
The deep layen are dosed in layers using a 5-0 polyglactic suture in an inverted buried manner. In the region
of the eyebrow, only one or two dermal sutures should be
used and superficial dermal sutures are avoided in order
to avoid damage to the hair follida. The cuticular closure consists of either a :fine fast absorbing gut suture or
a 6-0 polypropylene permanent suture, blue in color so
that the sutura can be easily seen upon removal. This
can be performed with simple interrupted or vertical mattress sutures. Sutures can be removed in S to 7 days. Scar

revisions may be necessru:y, but the authors wge patients

to wait 6 months after injw:y for appropriate healing and
maturation.

Complications
Complications associated with hair follicle damage
and avulsion injuries of the brow can lead to alopecia.
With meticulous technique, hair loss can be minimized.
Alopecia can oca:~r despite appropriate technique, and hair
transplantation can be comidered.
Facial nerve injw:y, specifically the temporal branch, can
result in frontalis muscle weakness or paralysis, causing

Chapter 75: Management of Soft Tissue Injuries of tite Face

forehead paral}'Sis and brow ptosis. Please see the following section on facial nerve injw:y.

Eyelids and Lacrimal System

1he lower eyelid anatomy can be divided into anteriot
middle. and posterior lamellae. The anterior lamella consists of skin and the Oibicularis oculi muscle which is
involved in squinting, blinking, and forced closure. The
middle lamella consists of the orbital sepwm, whereas
the posterior lamella includes the tarsus and conjunctiva The distinct layers of the eyelid become extremely
important as closure is attempted, with careful attention
to reappro:ximation of the tarsus and muscular anatomy to
restore the lid's protective functional role.
The upper eyelid lamellar anatomy is similar with the
exception of the levator palpebrae superioris muscle, which
forms an aponeurosis as it sweeps aver the globe and fuses
with the o:rbital septum. Dense attachments to the anterior lamella, as well as the anterior surface of the tarsus or
posterior lamella are also formed (26). These attachments
allow the levator muscle to elevate the upper lid. The sympathetically controlled Mueller's muscle adjoins the levator palpebrae superioris muscle and acts to provide tone
and static position to the upper eyelid.
The lateral canthal tendon (LCr) connects the tarsal
plates deep to Whitnall's wberde along the lateral orbital
rim. Superficial anterior and posterior :fibrous attachments
of the tarsal plate and fibers of the pretanal orbicularis also
attach to the lateral orbital rim (27).
The medial canthal tendon (Mer) is considered to be
the tendon of the pretarsal Oibicularis oculi muscle with an
additional posterior limb of the Mer from the palpebral
portion of the o:rbicularis oculi muscle. The lacrimal sac,
encased in fascia, is then bounded anteriorly, laterally, and
posteriorly by the constituents of the Mer and medially to
the bony fossa of the lacrimal sac (28).Injuries at the level
of the MCI' are in dose proximity to the lacrimal system
making concomitant injuries common.

1117

Ex:traocular muscle testing should then be performed

with attention paid to limitations in movement, which can
signify oibital soft tissue edema, extraocular muscle injw:y,
or entrapment from underlying fracwres. Examination of
the globe and anterior segment must be performed to identify the presence of foreign body, corneal injury, hyphema,
or rupwred globe (26).
Lacerations and avulsions should be examined with
assessment of both surfaces of the upper and IOWf!l' eyrlid,
along with adnexal sttucwres. Injuries to the medial canthal region raise the possibility of canalicular injw:y and
involvement. Facial sensation, eyelid position, and asymmetries as well as telecanthus &om underlying fractures
should also be noted (26).

aosure
After evaluation and removal of any debris or particulate
matter with copious irrigation attention can be turned
toward wound closure. Important considerations include
the use of corneal protectoiS before any injections, or
closures are attempted around the area of the globe.
Debridement should be fastidious and limited only to tissue deemed necrotic. The authon recommend the surgeon
to use loupes or magnification for closure of perioibital
injuries, and in many cases repairs in an operating room
are advocated. Appropriate and optimal use of anesthesia
and operating room staff and equipment is often best for
the patient even with a 24- to 48-hour delay in treatment.
with the exception of ocular emetgencies.
When performing closure of full-thiclmess eyelid margin lacerations, it is critical to address all layers using a
three-suwre technique to avoid and minimize long-term
sequelae. Avulsed segments of up to one-fourth of the lid
margin may be dosed primarily. F"mt. the cut edges of the
tarsal plate should be identified with the edges freshened
if needed. Mun:hison and Bilyk (26) recommends passing a single 6-0 prolene stitch at the meibomian gland
line. found slightly posterior to the dliar:y line (the lash
line) and gray line. to temporally act as a traction suture
and realign the eyelid maigin, without tying it (Fig. 75.7).

Evaluation
Significant moibidity can occur from injuries involving
the periocular area, with a substantial percentage of eydid
injuries presenting with accompanying canalicular and/or
underlying globe injw:y. Evaluation should include mechanism, ocular history, visual :field changes, blurred vision,
double vision, and visual acuity changes. Periocular swelling can be substantial, especially in delayed presentation,
where a standard Snellen acuity cannot be established. In
these cases near vision, finger counting, and light perception can be documented. Pupillary examination should be
performed with any evidence of asymmetries, shape distuibances, or poor reactivity necessitating ophthalmology
consultation. This can signify an underlying Hamer's syndrome. afferent pupillary defect, third cranial nerve palsy,
or damage to intraocular or intraorbital structures (2 6).

Figure 75.7 Closuna of the eyelid defect highlighting the realignment of the tarsus and the thnae suture technique for lid margin
repair. Sutures are placed at the level of the melbomlan glands,
gray line, and lash line. Ud margin sutures are left long to avoid
contact with the cornea. 1, meibomian orifice: 2, gray line: 3,
mucocutaneous junction: 4, Inferior tarsus and melbomian glands;
5, palpebral c:onjuncdva; 6, orbicularis oculi m.

1118

Section V: Trauma

The tarsus is then reapproximated with partial-thickness

sutures. Care must be paid to the lamellar boundaries
being careful to not pass into the conjunctiva to avoid
post repair corneal irritation &om suture material. Begin
near the eyelid margin and then proceed along the vmical
length of the plate using a S-O or 6-0 polyglactin suture.

Once the tarsus is realigned the eyelid maxgin traction

suture can be tied with long tails, followed by placement
of an anterior single suture at the ciliary line and an additional suture at the gray line (Fig. 75.8). Care must be talren
to avoid corneal irritation with the tails of the lid maxgin
sutures left long and draped onto the skin of the eyelid

F
Figure 75.8 A:. Full-1ftlckness InJury to the left eyelid with brow Involvement. 1: EJcposed globe
and periorbital fat conC41rnlng for levator InJury. C: Reapproxlmatfon of the levator (grasped by fol'ceps) with visualization of the Insertion Into the tarsus. D: Skin dosure with long tails left long and
lncorpon.rted Into a separate skin suture In order to avoid comeal Irritation. E,F: Postoperative out
come with appropriate brow realignment and mild lid contour deformity noted.

Chapter 75: Management of Soft Tissue Injuries of tite Face

where they are sutured to the Wlderlying skin. The skin and
orbicularis are then dosed with absorbable or nonabso:rbable suture in an interrupted or running fashion. Suture
material choices should be carefully considered in the
trauma population. However, if the patient is unlikely to
return a long-lasting abso:rbable suture may be used. 1he
lid margin repair should be with a nonabsorbable suture
to prevent premature dissolution or breakage
Upper eyelid injuries with herniation of fat and ptosis
are concerning for injury to the levator superi.oris muscle
or aponeurosis. Care must be taken to thoroughly explore
the wound and identify the levator muscle and/or aponeurosis with appropriate repair. The violated orbital septum
should not be repaired for concerns of eyelid retraction.
Lateral canthal injuries, whether from blunt,. sharp, or
penetrating trauma put the globe at risk, given the poor
bony protection laterally. Murchison and Bilyk advocate
two tenets in repair of LCf injuries. First, repair begins
by suturing and reapproximating the retinaculum of the
LCI' to the inner aspect of the lateral bony orbital rim at
Whitnall's tubercle. This maneuver will allow for appropriate functional aesthetic auvature of the lid and avoidance
of ectropion. The second principle addressea the lateral
canthal angle with a separate suture from meibomian
gland line on the lower lid to meibomian gland line of the
upper lid. This allows for a sharp lateral canthal angle (26).
The intimate anatomic relationship of the lacrimal
drainage system to the MCf make associated injuries more
frequent. Injuries medial to the puncta or those associated
with animal bites also confer an increased risk of canalicular
injw:y (29). Examination should proceed with careful and
methodical probing after anesthetizing the eye and lacrimal
puncta with topical ocular anesthetic, as this can otherwise
be quite uncomfortable for patients (Fig. 75.9). Especially
in the case of canalicular injury, direct anesthetic injection
can increase edema at the injury site making identification
and cannulation of the canalicular orifice mare difficult.
Injured canaliculi are then intubated with silicone stents,
either monocanaliailar or bicanalicular: Once identified
A. test patency of
canaliculus with

probe

B. Insert silastic
tubing in superior
punctum 1tten
Inferior punctum

C. Place suturu above

and below irrterior
canaliculus

6I
FiguN 75.9 Approach to canalicular injuries. A: Probing the
inferior canaliculus to test patency. B: Stent placament. 1, probe;
2, superior punctum and canaliculus; 3, inferior punctum and
canaliculus; 4, laaimal sac; 5, nasolaairnal duct; 6, NLD osteum;
7, middle turbinate; 8, inferior turbinate. C: Suture placament.

1119

and intubated,. further repair of the canalicular injury can be

Wlde:rtalren. Kersten and Kulwin (30) advocate repair of the
peri.canalicular o:rbicularis O<llli muscle. with reapproximation from stenting and a single mattress suture. Repair of the
Mer should be performed using a posterior medial vector
with deep absorbable suture placement in the periosteum.
Avulsion injuries with subsequent tissue loss pose a complex: reconst:ructi:ve dilemma. In addition, adequate corneal
protection is paramoWlt. With eyelid avulsion injuries, the
goals of repair are to create a functional eyelid with adequate tearing and preservation of vision. In selected cases,
a lateral canthotomywith cantholysis can be performed for
mobilization of additional tissue to aid in closure. In the
rare cases of total avulsion, corneal lubrication and protection take precedence and delayed multistage reconstruction
will be necessaxy. Bacittacin ophthalmic ointment should
be applied twice daily in the care of wounds and lacerations of the perio:rbital region. Canalicular stents remain in
place for 12 weeks and can be removed in the clinic setting.

Complications
Despite timely and appropriate care, these injuries can
result in periorbital and eyelid complications. Many can
be managed conservatively with observation, such as mild
eyelid malposition treated with digital massage H~
those with moderate to severe dystopia. significant corneal
exposure, lagophthalmos or ectropion, will require further
intervention to avoid exposure keratopathy and improved
cosmesis. Ptosis oca.m with levator injuries and even with
repair it may take several months for resolution. Other complications include notching of the lid margin and epiphora.

Nose
lhe nose is particularly susceptible to injury given its
prominent position and is a commonly injured site following facial trauma Injuries of the nose can result in disfigurement from scarring and distortion, as well as functional
abnormalities such as nasal obstruction.
Nasal anatomical relationships become functionally
important at the level of the nasal valves both internal
and external. The external nasal valve is at the level of the
nasal vestibule, alar lobule, and caudal septum. The internal valve is at the level of the caudal margin of the upper
lateral cartilage, with the nasal septum medially, and the
inferior turbinate at the inferolateral position.

Evaluation
Examination of nasal trauma should start with simple
frontal inspection, and note any deviation or asymmetty to
the nose. Associated facial, nasal, or septal fractures should
be recognized. Anterior rhinoscopy should also be performed using either a nasal speculum or fiberoptic endoscope examining for acute septal deformity, dislocation,
hematoma, mucosal teals, and CSF leak.
Nat attention should betumed to cutaneous lacerations,
noting any involvement of Wlderlying cartilage, avulsed or

1120

Section V: Trauma

missing tissue or through and through involvement. Severe

nasal injuries, such as nasoethmoid fractures warrant formal ophthalmologic examination, since up to 59% of midface fractures have associated ocular injuries (5).

Closure
Repair of soft tissue injuries to the nose follows the same
guidelines as closure of all facial wounds, with excellent
functional and cosmetic outcomes as the primary goal.
Wounds are classified by depth and assessment of tissue
loss in the case of avulsion injuries. Superficial lacerations
extending into the subcutaneous tissues can be closed with
the use of absorbable deep dermal sutures, and the surgeons preferred suture for skin closure.
Cartilaginous involvement is addressed with meticulous
alignment and prevention of deviation or collapse. The
use of nonabsorbable or long-lasting absorbable suture
for reapproximation is preferred, and in the case of lower
lateral cartilage involvement the use of interrupted nonabsorbable polypropylene suture is preferred for appropriate
wound support and durability.
Full-thickness lacerations involving the skin and nasal
mucosa are closed in layers beginning with the nasal mucosa
using a 5-0 chromic suture in an interrupted fashion. Then
this is followed by closure of the muscular, cartilaginous, dermal, and skin layers as outlined above. Many times the alar
rim or alar lobule is involved and thus there is particular concern of post repair notching. Care must be taken to ensure
appropriate alignment of these structures in particular.
Avulsive wounds of the nose are a common form of
presentation, and repair may involve primary closure. skin
grafts, composite grafts, or local flaps. Complex reconstruction is not appropriate in the acute setting.
An intranasal silastic stent can be placed to avoid or
minimize vestibular stenosis or collapse.
CompUcations
Complications of nasal injury may result in vestibular stenosis and nasal obstruction. Deformities include scarring. alar
sidewall collapse, and alar retraction. Hypertrophic scarring
can also be seen in select individuals. Infection following an
undiagnosed septal hematoma can be seen days later and
must be kept in the differential if the patient reports acute
onset of increased pain, nasal obstruction. and signs of fever.
This would necessitate emergent incision and drainage.

Cheek and Parotid

The parotid gland is the largest of all salivary glands with
its position in the retromandibular space between the
ramus of the mandible and mastoid process. The gland is
invested in a dense fibrous capsule derived from the investing layer of the deep cervical fascia. and over this fascia lays
the SMAS. The SMAS also serves as the attachment for the
muscles of facial expression. The deep aspects of the gland
pass through the stylomandibular tunnel to rest within the
parapharyngeal space (31).

The parotid duct (Stensen's duct) travels across the surface of the masseter in a horizontal plane. On reaching the
anterior border of the muscle, the duct's course turns medially as it pierces the buccinator muscle toward the oral cavity. The mucosal papilla opening is found in the oral cavity
opposite the second upper molar. Traveling along side
the duct, in a predictable anatomic fashion, is the buccal
branch of the facial nerve. This relationship on the superficial aspect of the masseter muscle makes the duct and
nerve more vulnerable to injury, thus must be considered
in soft tissue trauma of the cheek and parotid region.

Evaluation
Recognition of parotid injury is essential to avoid late complications. When examining the patient, the wound should
be explored for evidence of clear drainage suspicious for
saliva. This can be accomplished by massaging the gland
and inspecting for presence of saliva within the wound. If
an injury has been missed, the patient may report swelling
in the area of the dosed laceration, especially after meals
over the course of the next few days.
If parotid injury is suspected, the wound should be thoroughly examined within 24 hours to avoid surrounding
inflammation and edema from obscuring the ductal and nervous structures, and subsequent injury during exploration.
Facial nerve examination, with particular attention to
the buccal nerve branch, should be conducted with any
weakness documented. The course of the parotid duct
and associated buccal nerve can be projected using a line
drawn from the tragus to the midportion of the upper lip
(Fig. 75.10). Injuries violating this line must then be
inspected for ductal and neural injuries. Discussion of
facial nerve injury is presented elsewhere in this chapter.
Patency of the ductal system can be assessed either with
simple cannulation using a silicone catheter, retrograde
injection with methylene blue or saline, or sialography.
The author advocates simple cannulation using a lacrimal
probe or silicone catheter.
Closure
In 1981, Van Sickels constructed a classification system
for anatomical regions of injury in parotid trauma with a
recent update of this schema (31,32).
Anatomic regions are divided into A, B, and C with divisions based on their relationship to the masseter muscle.
Prognostic and treatment information can be derived from
this classification system. Region A is the area posterior to
the masseter with likely injury to the parenchyma of the
gland. Wounds in this region can safely be closed in layers
with particular attention paid at the level of the SMAS ( 31).
Region B is associated with the area overlying the masseter muscle, and carries the highest risk of ductal injury.
Ductal injury increases healing time from continued salivary flow into the wound. If injury of the ductal system is
visualized or suspected, cannulation of the duct through
the papilla using a silicone catheter or stent should be
passed retrograde. The lacerated end will be identified and

Chapter 75: Management of Soft Tissue Injuries of tite Face

1121

bacteria (33). A second- or third-generation cephalosporin, clindamydn, or amoxicillin with clavulanic add is usually sufficient. with considerations for methicillin-resistant
S. aureus in persistent infections.

Complications
Injuries to the parotid and cheek region can result in prominent facial scarring and disfigurement. Specific to the thia
region one can also see gustatory sweating (Frey syndrome),
sialocele formation, and salivaJ:y-cutaneous fiswla.
Late complications are increased if the techniques
noted are not employed or the injury goes unrecognized.
Nonsurgical management is described above Formerly,
tympanic neurectomy was a consideration for those cases
where a decrease in salivaJ:y flow was therapeutic. Now this
has been largely abandoned due to the effectiveness ofbotulinum toxin injection. If all options have been exhausted
in the setting of persistent fiswla, parotidectomy may be
entertained. 1his poses a challenge for safe facial nerve dissection in the setting of mensi:ve scarring and fibrosis &om
the injury and fiswla.

Facial Nerve Injury

FiguN 75.10 Parotid duct anatomy. lnjuri89 violating a line
drawn from the tragus to the upper lip should raise cone~~m for
injury to the parotid duct.

the opposing proximal transected duct identified. The ends

are then dissected free to allow for tension-free closure of
the severed ends over the silicone catheter. Microsurgical
techniques, using a 7-0 to 9-0 mono:filament suture. are
employed for closure (Fig. 75.11). 1he catheter is then
sutured to the buccal mucosa for 10 to 14 days to hold the
duct and orifice open during healing. Ifthe injury precludes
this, the end of the proximal duct can be brought out to
the buccal mucosa and sialodochoplasty is performed.
Rfgion C is the area anterior to the masseter muscle. In
this region, the distal duct or papilla is injured and reanastomosis may not be feasible. It may be necess;uy to divert
the duct into the buccal mucosa, thereby creating a new
duct orifice as noted above. A stent is left in place at the
newly constructed papilla (31 ). Some authoiS mention
parotid duct ligation of the proximal section resulting in
arute parotid swelling, pain, and salivary back-flow with
eventual glandular attophy. We do not advocate this.
If appropriate. techniques to reduce salivary flow or
reduce accumulation include placement of compressive dressings, and anticholinergic medications. In recent
years, botulinum toxin A (Botox. Allagen Inc. Irvine. CA)
has been sucassfully used in these circumstances as well.
Some patients may require needle aspiration of accumulated saliva post closure.
Antibiotic coverage in the setting of injury or post injury
sialocele should include coverage for Staphylococcus aureus,
Haemophilus influenzae, and anaerobic Gram-negative

The anatomical considerations of the facial nerve are summarized here as they relate to arute soft tissue injwy of the
face. Discussion is limited to the e:xttatemporal coUISe of
the facial nerve as it exits the stylomastoid foramen and
innemltes the muscles of facial expression, posterior digastric belly, and posterior auricular and stylohyoid muscles.
Innervation to the muscles of facial expression is all along
the deep surfaa! of the muscle with the exception of the
levator anguli oris, bucdnato~ and mentalis muscles. This
anatomical relationship is important in cases of penettating injuries and exploration to avoid iatrogenic injury.
Transection of the main trunk results in complete facial
paralysis, while injuries distal to the pes anserinus or muscles themselves, will result in inability to move the involved
area of the face (34).
Injury to the facial nerve can have devastating consequences resulting in diminished emotional expression
for patients attempting to smile, frown, or grimace. The
functional aspects affecting oral competence can be disabling and may limit social activities, eating habits, and
speech. The protective mechanism of the facial nerve
should also be considered, with innervation to the stapedius muscle as well as the o:rbicularis oculi muscle,
providing eye closure and the blink reflex. Severe keratopathy from unrecognized chronic corneal exposure
may lead to blindness.

Evaluation
Once the patient is stabilized and able to cooperate. facial
nerve function should be tested. Other cues such as grimacing in the presence of a noxious stimulus can also
aid in assessment for patients who are Wlable to perform

1122

Section V: Trauma

Fig... 75.11 Cannulation and repair of parotid duct. 1, lacaration; 2, Stenson's (parotid duct);
3, parotid gland; 4, ma99eter m.; 5, bua:inator m.; 6, trans&cted buc:ral branch. A: Right cheek.lacarauon with 98Vered duct and nerve branch. B-E: Duct cannulation and repair.

volitional movements. The examiner should ask the patient

to raise their eyebrows, dose their eyes, smile, purse and
puclrer the lips, and puff out their cheeb (34). Complete
transection results in complete paralysis with no volitional
movement Crush injuries often present with normal function followed by partial or delayed paralysil!l, often with
resolution with expectant management.
Several grading systems have been proposed with
the most widely accepted and used being the HouseBrackmann scale (see Chapter 155). Although other rating
systems have been introduced, the authors prefer conscientious documentation using terminology that identifies the
branches involved and the degree of paresil!l {34).
When evaluating the patient. an imaginacy vertical
tangent can be drawn from the lateral canthus inferiorly
and injuries anterior to this line are not explored for facial
nerve injury. The highly redundant collateral innervation
from other branches makes recovery likely, as well as the

fact that the small diameter of the nerves anterior to this

line makes identification and reanastomosis difficult.
Exploration of the WOWld may reveal transected ends
of the nerve. 1he use of a nerve stimulator for the distal
branches can aid in identification for up to 72 hours, after
which Wallerian degeneration occurs and compromises
excitability of the nerve.

Closure
Facial nerve injuries should be explored and repaired as
soon as possible. When nerve identification and repair is
anticipated, the procedure should be done in the operating room Wider general anesthesia, as lidocaine would
create inability to use a nerve stimulator. In the critically ill patient. the injured branches should be tagged
with permanent suture or dips on adjacent til!lsue can be
placed. Then reanastomosis can be performed once the
patient is stable.

Chapter 75: Management of Soft Tissue Injuries of tite Face

1123

Primaxy neural repair provides the best chance for return

of facial nerve function. this can performed with the operating microscope using 8-0 to 10-0 monofilament nylon
suture. Tension-free closure of the epineural layu- should
be pe:rformed, although some authol'8 recommend perineural repair as having the potential advantage of reducing
synkinesis and mass facial movement (34-36).
When a tension-free direct repair ia not possible,
cable (interposition) grafting ia advisable The use of
great aurirulat sural, and medial antebrachial cutaneous
neiVes offeD the best option for achieving wlitional facial
movement (37).
When facial nerve repair is not possible, facial reanimation procedures can be performed at a later date

Complications
Complications in the setting of facial nerve injw:y include
inability to repair the neiVe injury, facial nerve paraly!is,
synkinesis, and mass facial movement. Often unprevmtable, the risk of complications can be reduced with early
recognition and management. Late complications include
corneal injw:y from inability to attain complete~ closure
with associated diy eye and kf!ratopathy. In addition oral
incompetence, brow ptosis, and dysarthria may result.

Au ride
1he ear typically protrudes from the head at an angle of
25 to 30 degrees with 15 degrees of incline ThilJ prominent
position opens the ear to frequent lacerations and shearing forces leading to avulsions. The e:xternal ear consists
of the auricle and EAC. The skin is tightly adherent over
the compliant cartilaginous framework of the ear covered
by perichondrium. The surface anatomy of the ear offers
a complex topography making replication and reconstruction diffirult (Fig. 75.12). Even if early repair is instituted,
severe traumatic auricular injuries may require multiple
procedures for reconstruction (38).

Figure 75.12 Anatomy of the external ear. 1, helix; 2, scaphoid

fossa; 3, antihelix; 4, auricular tubercle; 5, triangular fossa; 6, crus
helicis; 7, cymba concha; 8, cavum concha; 9, external auditory
meatus; 10, tragus; 11, antitragus; 12, lobule.

width discrepancies can be compared with the contralateral ear. Debridement should be minimized given the relative lack of available skin for closure and cartilage coverage
Closure
Lacerations of the EAC rarely necessitate suture repair.
Stenting with nonabso:rbable sponges should be instituted if stenosis is a consideration, but only after tympanic
membrane ewluation.
Isolated lobule injuries can be repaired with primaxy
layered closure or z..plasty techniques to prevent any notching at the inferior margin of the lobule Cutaneous injuries
of the ear with cartilage exposure are managed by primaxy
closure Full-thickness skin grafts can also be used for cartilaginous coverage in cases of isolated skin loss or to avoid
nimming cartilage in avulsion injuries as to not decrease
the size of the ear (Fig. 75.13).

Evaluation
Examination should start with inspection of the EAC as
lacerations at this site can potentially lead to EAC scarring
and stenosis. The EAC should be cleaned of any debris or
blood. Integrity of the tympanic membrane should be confirmed and hearing loss identified. Tuning fork examination is an appropriate initial measure and an audiometric
testing can be performed if hearing loss is a concern.
Examination of the postauricular region for evidence
of mastoid tenderness or ecchymosis (Battle's sign) concerning for basilar skull or temporal bone fractures should
be performed. Radiographic imaging to evaluate for fractures or dislocations should be pe:rformed if concern exists.
Cranial nerve ez:amination should be performed with special attention paid to the ipsilateral facial nerve
Inspection of the wound should be performed, noting
the extent of cartilaginous involvement or loss. Height and

Figure 75.13 Auricular InJury with c:~xpoSQd cartilage. Repaired

with FTSG without further loss of aurlde siZCil (3 month result).

1124

Section V: Trauma

Patients with full-thidmess loss of skin and cartilage

present a challenge. For helical defects a wedge excision
technique may be used. This can be safely perfonned up to
5 mm without threat of auricular deformity. Reconstru~
options should aim at complete cartilaginous oovuage with
care to achieve a tension-free closure. If the full-thickness
defect is small (less than 1.5 an), the cartilaginous remnants

Figure 75.14 Approach to auricular Injuries with

cartilaginous Involvement. A: Full-thickness lac
eratlon with cartilaginous Injury. 1: Repair of the
cartilage and perichondrial layer using polydloxanone. C: Skin dosure.

can be trimmed and closed using a polydioxanone monofilament suture in an interrupted fashion using a taper needle
to avoid cartilaginous tears. this allows for maintenance of
auriOJlar proportions, but may reduce the averall size of the
ear dependent on the amount of missing tissue (39). Skin
closure is accomplished using intemlpted 5-0 polypropylene or abso:rbable monofilament suture (Fig. 75.14).

Chapter 75: Management of Soft Tissue Injuries of tite Face

Awlsion injuries should be scrutinized for disruption of

blood supply and degree of tissue loss. Injuries with a narrowvasrularpedide may be dosed but the patient should be
oounseled about possible impending tissue loss. The authors
feel that primary closure should be attempted, allowing further demarcation and necessary debridement In the setting
of complete auricular avulsion, reconstruction algorithms
are dictated by whether the ear is found at the scene. In the
case of a missing auricle, the wound should be dosed amprimarily and delayed reconstructive options discussed with
the patient. including future auricular reconsttudion using
oostal cartilage grafts vmus prosthesis placement
If the avulsed segment is found, care must be taken in
the storage and transport of the ear. The tissue should be
wrapped in gauze and placed in a plastic bag, which il!l
placed in an ice bath at 4c, avoiding direct contact with
water. If microvascular expertise is available, the amputated
segment should be evaluated using an operating micr~
scope for identification of suitable vessels for microvascular reimplantation. 'Ibis offers the highest sw:vival rate
for the reimplanted ear (38,39). Pocket techniques are
described in which the segment il!l dermabraded, attached,
and buried in the postauricular skin with later exposure of
the attached segment (38). 1he authors generally advise
against manipulating the postauricular skin in any way as
this il!l the most useful skin in definitive reconstruction. The
pocket principle has fallen out of favor and banking cartilage in remote soft tissue sites seems to add no advantage
to reconstructive options.
Exposure or involvement of the cartilaginous framework
increases the risk of perichondritil!l substantially. Cartilagepenetrating antibiotics effective against pseudomonas

should be used with fluoroquinolones serving as a firstline therapy. In the event of EAC involvement. antibiotic
otic drops are prescribed for S to 7 days.
Some ear injuries require a bolster to avoid auricular
hematoma due to dil!lruption of the cartilage with accumulation of blood within the cartilage fragments or the
subperichondrial space. Bolsters can be fashioned using
dental rolls or ointment-impregnated gauze with mattras
sut:ures to eliminate dead space (Fig. 75.15). Undue pressure should be avoided as necrosis may result. Others have
described use of thermoplastic splints as a shape-forming
bolster (40,41 ). The bolster and EAC wick should be left in
place until follow-up at the time of suture removal at 5 to
7 days.

Complications
Injuries involving the external ear can lead to a multitude of
complications and concomitant injuria. Close follow-up
should be maintained to evaluate for chondritis, temporal
bone fracture, and associated hearing loss from ossicular
disruption, tympanic membrane perforation, or EAC stenosis. Facial nerve integrity should be monitored as well.
Acaunulation of intracartilaginous blood or blood in
the subperichondrial plane can lead to auricular hematoma, which can be managed with simple needle aspiration (for small isolated hematomas) or incision and
drainage with use of a bolster (for more extensive hemat~
mas) (42). Unrecognized hematoma can result in cartilage
loss. necrosis and formation of neocartilage and fibrosil!l
giving the ear a cauliflower ear deformity. This deformity
can be disfiguring and difficult to manage, with repair
requiring surgical excision of the neocartilage and fibrosis

Evacuate heatoma and place bolsters wlltl1hrcugh and

1hrough sutures

1125

B
Figure 75.15 Auricular hematoma. A:. Blood may aa:umulat& wlthln the cartilage fragments or In
the perichondrial space. 1, skin: 2, perichondrium; 3, cartilage; 4, hematoma. B: Evacuation of the
hemiJtoma ls followed by plac:ei'I'Kint of a bolster dressing with through-and-through sutures.

1126

Section V: Trauma

using camouflaging incisions. Best practice ia avoidance

and the judicious use of bolsters.

Lips and Chin

The lip and perioral region embodies both aesthetic and
functional components that must be considered in the setting of soft tissue repair. The anatomy of the lip demonstrates su:rface contow:s that the human eye ia drawn to, such
as cupid's bow; philtrum, and the vermilion border. The red
lip ia comprised of three layem, the outer vermilion layet
the middle muscular layer (of the Oibicularis oris), and the
inner mucosallaya-. At the junction of the facial skin (white
lip) and theVi!I1Ililion (red lip) is thevermilion borderwith
corresponding red and white rolls. the rellecting of light
at these rolls makes any injury with even a one-mm misalignment at the vermilion eye-catching and aesthetically
unpleasing (4). the mental crease is a horizontal groove
between the area of the chin and lips influenced by the mentalia muscle. Realignmentoflacerations in thia area contributes to a natuml division between the lip and chin regions.
the primuy blood supply to the perioral region is the
facial arteiy giving rise to the inferior and superior labial
arteries which encircle the mouth. Injwy here can lead to
brisk bleeding making initial evaluation difficult.

Evaluation
As the lip and perioral region are examined, sensoJY and
motor function should be documented, aa well as depth
and location of the injury. Any extension into the floor of
mouth and buccal mucosa should alert the clinician to
potential involvement of the salivary ducts. The lips and
mucosal surfaces should be examined for associated injuries including changes in dental occlusion and broken or
missing teeth. If injuries are present. consultation with the
dental team may be necessuy prior to repair in order to
avoid undue tension and retraction on the suture line during dental repair (4, 7).

2
2
2 _,._,;_

..

2
2a

J, s
-:=- 3
3

\'' 3

Figu,. 75.16 Layered lip dosure. Layered dosure of the lower

lip highlighting the realignment of the vermilion and orbicularis
oris musde. Mucosal and skin closure also depicted. 1, mucosal
sutures; 2, vermilion sutures; 2a, suture at the vermilion cutaneous
border; 3, skin (dermal) sutures; 4, orbicularis oris musde sutures.

the most important stitch in lip reconstruction is next.

Marking its importance, placing this suture first could also
be considered. Using a permanent monofilament suture,
such aa a 6-0 polypropylene (Prolene), a single stitch is
placed to align the vermilion border. This will allow accurate reappro.ximation, while the remainder of the vermilion (red lip) is then closed using simple interrupted 6-0
prolene sutures (Fig. 75.16). Facial skin closure is performed in standard layer fashion.
Chin lacerations should focus on recreation of the natural bordeD and surface landmarlaJ without creating any
traction on the lower lip, which is subject to inferior displacement.
Ifthere ia more than 30% loss of the lip, primary closure
may lead to relative microstomia and undue wound tension. If the defect is too l;uge for primaJY closure the edges
of the defect can be closed and the full-thiclmess defect can
be reconstructed at a later date. Closures outside of primru:y repair should be deferred for secondary reconstruction using various lip flaps such as .Abbe. Esdand~ and
Karapandzic flaps and are beyond the scope of thia chapter.

Closure
The first step of repair is marking of the vermilion border
before its boundaries are lost from edema or injections
around the site of injury. When appropriate, the use of
regional blocl<s allows the surgeon to evaluate and repair
the vermilion border without distortion.
the main tenant of primary closure of lip lacerations is
the layered closure, with reapproximation of the orbicularis
oris muscle and alignment of the vermilion border. Whether
:first or last. the mucosa should be dosed, usually performed
with interrupted absorbable 4-0 polyglactin sutures, using
la1ge bites to avoid sutures tearing or eroding mucosa.
Critically important is reappro:ximation of the orbicularis
om muscle to restore sphincter function, and to avoid muscular dehiscence of contraction with healing. A soft tissue
deficiency, usually seen months later;. is apparent in those
cases where the muscle laya- is not well approximated

Complications
Post-traumatic lip deformity is the most common complication following injwy. this ia not unexpected given the
delicate and intricate anatomical features of the lip. The
degree of the deformity is directly related to the severity of
the injury and the complexity of the repair. Resulting deformities include misalignment of the vermilion, cutaneous
scan, and contour deformities of the red or cutaneous lip.
Skill, experience. and expertise help minimize this risk and
metiallous closure must be performed with special attention paid to alignment of su:rface landmarb and layered
closure. Muscular contracture and notching of the lip are
common sequelae following inaccurate closure. Functional
complications, such aa microstomia or oral incompetence,
may oCOJJ and appropriate delayed reconstruction must be
considered.

Chapter 75: Management of Soft Tissue Injuries of the Face

SPECIAL CONSIDERATIONS

Bites
Injuries from bites are becoming more common with 15%
of all bite wounds occurring in the head and neck. According
to Gilchrist et al. (43) 4.3 7 million people were bitten annually in 2001 to 2003, and, of these. 83 6 000 ( 19%) required
medical attention, with more than 31,000 patients undergoing acute repair procedures in 2007 as the result of dog bites.
Dog bites makeup the majority of animal bites (80% to
90%), with cats as the second most common (5% to 15%).
Human bites account for 3% to 23% (19). Most injuries are
from the patients' own pet, or pets that are lmown to them,
as opposed to stray or mongrel animals. The size and age of
the child is inversely proportional to the level of risk for bite
injuries to the head and neck ( 44). Other bites from more
exotic and less common pets are beyond the scope of this
chapter. Yet, it should be mentioned that the type of animal
bite becomes important in antibacterial management, and a
thorough history should be elicited.

Microbiology
Infection after bites can originate from the bacterial flora
of the animal or human's oral cavity, as well as the skin
of the victim. The overwhelming majority of bite infections are polymicrobial, with 2.8 to 3.6 bacterial species
isolated in wound cultures of both aerobic and anaerobic
bacteria (44). Life-threatening viruses may also be transmitted from animal bites and must be considered during
the evaluation.
Dog bites offer the lowest infection rate of common
animal bites, with risk factors of significant crush injury,
devitalized tissue, deep puncture wounds, exposure of cartilage, or delay in seeking care beyond 6 to 12 hours all
resulting in increased infection rates (19,45,46). Pasteurella
species are often discussed as the most common pathogen involved in dog bite infections, but the overwhelming
majority are polymicrobial with numerous studies isolating various species including Staphylococcus sp., Streptococcus
sp., Corynebacterium sp., Moraulla sp., and Neisseria sp.,
Bacteroides fragilis, Fusobacterium, and Peptostreptococcus
(19,44,45). Additionally. the possibility of transmission of
the rabies virus exists with dogs accounting for the majority
ofhuman rabies cases worldwide. In the United States, howeve~; human transmissions are more commonly from wild
animals such as skunks, raccoons, bats, and foxes (19,44).
Cat bites have higher rates of infection with more rapid
progression when compared to dogs. Cats' teeth often produce deeper puncture wounds, given their shape, inoculating bacteria deeper into the wound. Pasteurella multocida is
the pathogen most commonly involved, resulting in 50%
to 75% of cases of infections from cat bites, although infections are frequently polymicrobial (19,45).
Human bites are less common than dog and cat bites,
but carry the highest infection rate at 25% in the head and

1127

neck region, likely secondary to the composition of the bacterial oral flora in humans (19,47). Although polymicrobial, the most common pathogens isolated in human bite
wounds includeS. aureus, Staphylococcus epidermis, viridans
streptococcL Eikenella corrodens, and anaerobic bacteria such
as B. fragilis (19,44,45). Additionally. viral transmission of
hepatitis B and C, herpes simplex virus, and human immunodeficiency virus (HIV) through human bites have been
reported (48). Although not common, in cases of lmown
or suspected infection by the assailant. appropriate screening and prophylaxis should be implemented. Hepatitis B
immunoglobulin should be administered to victims if they
are not already vaccinated, in cases of known Hepatitis
B-infected attackers. If the biter is HN positive, the victim's
baseline serologic testing should be obtained, with retesting
at 3 and 6 month intervals. If possible. titers for HN viral
load should be obtained from the attacke~; and if elevated,
prophylaxis should be offered to the victim (19).

Evaluation
Animals are often drawn to the nose and cheeks of children when attacking, making ocular examination an integral part of the examination. The patient's immunization
status should be elicited and appropriate tetanus treatment
given.
Classification systems have been proposed, with the
majority of superficial wounds repaired in the emergency
department, while those with extensive or deep injuries managed in the operating room ( 19). The wounds should be copiously irrigated with normal saline to reduce the inoculum.
The wound should be debrided of devitalized or necrotic tissue to promote healing and reduce the risk of infection.

Closure
Most head and neck bite wounds managed acutely can be
dosed primarily. This decision has been controversial, with
the risk factors of delayed presentation, type of wound, and
species inflicting the bite all modifying the debate. Current
recommendations are to repair all bite wounds of the head
and neck on presentation within 24 hours of the injury,
assuming there are no signs of infection (19,45,47). For
those wounds presenting outside of the 24-hour period,
many authors feel that wound care and treatment with
antibiotics before definitive closure will decrease infection
rates. Wounds not amenable to primary repair may require
more complex repairs using skin grafts and local flaps (19).
For massive midface tissue loss, facial composite tissue
allotransplantation has been reported. In these cases, frequently. dog bite injury is cited as the inciting event

Antibiotics
Prophylactic treatment of bite injuries is controversial as
little data exists to support their benefit in cat and dog bite
wounds presenting within 6 hours ( 49). The authors support recommendations for antibiotic treatment in all deep
injuries with muscle and cartilage involvement, children,

1128

Section V: Trauma

wounds older than 6 hours, cat bites, human bites, and

individuals with immunosuppressive comorbidities
(19,50). Stierman et al. (47) recommends 48 hours of
intravenous prophylactic antibiotic therapy prior to closure
for human bites to the ear, given the significantly increased
risk of infection noted at this particular site.
Empiric oral prophylaxis for cat, dog, and human
bites can be covered with amoxicillin and clavulanate
875 mg/125 mg twice daily or the combination of doxycycline with metronidazole in penicillin-allergic patients.
Alternative regimens include clindamydn plus ciprofloxacin, whereas trimethoprim-sulfamethoxazole is appropriate for children. Azithromycin is also acceptable for use in
penicillin-allergic children and pregnant women (19).
Bite wounds found to be infected at delayed presentation merit intravenous antibiotic treatment. Recommended
first-line agents are ampicillin and sulbactam, piperacillin with tazobactam, or clindamydn in penicillin-allergic
patients. The parenteral course is given for a minimum
of 48 hours followed by oral equivalents totaling 10 to
14 days of treatment (19).

Burns
The head and neck region accounts for only 9% of the
total body surface area when calculating involvement in
burns. However, significant facial burns require specialized trauma protocols for airway establishment and fluid
resuscitation, preferably in the setting of a certified bum
center. Considerations for tracheotomy are delayed due to
increased risk of infection.
The depth of bums is a critical factor in making treatment decisions. Superficial burns are isolated to the epidermallayer and may be managed with saline irrigation and
strict wound care using topical antibiotic ointments and
specialized dressings, while avoiding systemic antibiotics
because of the tendency to develop bacterial resistance.
Superficial partial thickness burns may be treated similarly
with resulting scars and contractures addressed secondarily.
Deep partial-thickness and full-thickness burns vary in their
treatment regimens amongst bum specialists. Many advocate for early excision and grafting using split-thickness skin
grafts to the face, while conservative wound management
is practiced by others (51). When planning skin grafts, the
concepts of facial aesthetic units are used as a guide to optimize future contracture by grafting thick grafts over entire
aesthetic units. Physical and occupational therapists play an
essential role, helping avoid contracture through the use of
range-of-motion exercises, pressure dressings, and splints.
Certain areas of the head and neck have unique considerations in treatment. The ear is quite often involved in
head and neck burns given its prominence. The resulting
burn is susceptible to suppurative chondritis, which should
be managed with incision, drainage, and debridement
along with local wound care. If there is evidence of cartilaginous exposure or damage then considerations for graft

or flap coverage should be instituted. The authors favor

local wound care with wet to dry dressing changes, allowing granulation formation, followed by STSG or FfSG.
Eyelids are involved in up to 2 7% of bum patients,
and initial management should be directed at examination and protection of the globe (52). The globe is often
spared due to protective mechanisms such as the blink
reflex and instinctive protective movements of the arm to
cover the face (53). Management begins with lubrication
of the globe and protective dressings. In the setting of lagophthalmos placement of a temporary tarsorrhaphy suture
is recommended (26,54). If both eyes are involved requiring suturing the lids closed, the patient should be sedated
for comfort. Definitive treatment for major full-thickness
burns will require early intervention with the use of splitthickness and full-thickness skin grafting (26).
Lip and perioral injuries from burns sometimes are secondary to electrical injuries from children biting electrical
cords. Early eschar removal is not advocated, with many
delaying surgical treatment to allow demarcation of the
involved area. Nonsurgical conservative management after
epithelialization has gained favor, using oral appliances
and splints to reduce microstomia even in the setting of circumferential burns ( 4 ). Scar revision or contracture release
can be performed secondarily with a variety of reconstructive techniques available.

Frostbite
Cold injury to the head and neck region most often involves
the ears, nose, and cheek due to reflexive vasoconstriction
in the setting of cold exposure. This directs blood away
from these tissues allowing local temperature drops in the
skin and eventual tissue freezing. Ice crystals may form on
the skin surface drawing intracellular fluid from out of the
cells and leading to irreversible injury. Hypoxia ensues followed by ischemia with thrombosis, dermal necrosis, and
acidosis with cell death (5,55). Initial treatment is conservative and is directed to rapid rewarming through use of
heated compresses or immersing the body part in a warm
bath maintained at lOO"F to 108"F. Although once considered optimal treatment, slow rewarming has been shown
to lead to further tissue damage (55). It is critical to provide appropriate analgesia as the rewarming process is
extremely painful. Antibiotics may be indicated as well as
tetanus prophylaxis. Sufficient time should be allowed for
demarcation before surgical intervention is recommended.

PEDIATRIC SOFT TISSUE INJURY

The same tenants of soft tissue injury evaluation and management should be followed in the pediatric age group as is
recommended in the adult population. With anxious and
uncooperative children, judicious use of sedation or general
anesthesia may be needed for wound evaluation and repair.
In hopes of avoiding postoperative struggle and fear during
suture removal, the preferred choice of sutures used in most

Chapter 75: Management of Soft Tissue Injuries of the Face

repairs is absorbable skin sutures or closure with subrutirular sutures. In the appropriate setting. wound closure may be
performed with cyanoacrylate glue (Dermabond, Ethicon
Inc., Somerville. NJ). If the mechanism of injury does not fit
the wound pattern or if suspicious behavior is recognized,
the surgeon should consider abuse as a potential cause.

The evaluation begins with stabilization following

the ABCDE's of trauma management.
Liberal use of irrigation and gentle tissue handling
optimize tissue healing minimizing the risk of tissue loss and infection.
Local wound care and secondary healing should
be considered in patients with grossly contaminated wounds, those with delayed presentation, and
patients with extensive skin and soft tissue loss.
Delayed closure is appropriate for grossly contaminated wounds, selected animal bites, infected
wounds, and when presentation is greater than
24 hours from injury.
Tetanus vaccination history is of critical importance
in any trauma patient.
Once the sutures are removed extreme care must be
taken to avoid sun exposure, and the use of broad
spectrum UV-A and UV-B sun block with a SPF
greater than 45 should be recommended for a minimum of 6 months to 1 year to prevent scar hyperpigmentation.
When performing repair of full-thickness lacerations of the eyelid margin, it is critical to address all
layers and the use of the three suture technique for
the lid margin alignment.
Upper eyelid injuries with herniation of fat and ptosis are concerning for injury to the levator muscle or
aponeurosis.
Any eyelid injury, which involves the punctum or
the tissue medial to the punctum likely involves the
canalicular system. Repair involves cannulation and
stenting of the lacrimal drainage system.
The parotid duct and buccal branch of the facial
nerve lie in a vulnerable location as they cross the
masseter muscle, and both must be considered in
soft tissue trauma of the cheek and parotid.
Acrumulation of blood in the subperichondrial
space or within the cartilaginous fragments can lead
to aurirular hematoma, which can be managed with
simple needle aspiration for focal collections versus
incision, drainage, and a bolster for larger ones.
The main tenant of lip laceration repair is layered
closure of the vermilion, skin, muscle. and mucosa.

1129

Dog bites makeup the majority of animal bites

(80% to 90%), with cats as the second most common (5% to 15%). Human bites account for 3% to
23% of cases.
Human bite injuries can be associated with viral
transmission of hepatitis B and C, herpes simplex
virus, and HN.
For severe facial bums, many advocate early excision
and grafting using split-thickness skin grafts.
With frostbite injuries, the initial treatment is conservative and revolves around rapid rewarming through
use of heated compresses or immersing the body
part in a warm bath maintained at 100 op to 108 oF.

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48. Morgan M. Hospital management of animal and human bites.
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49. Medeiros I, Saconato H. Antibiotic prophylaxis fur mammalian
bites. Cochrane Database Syst Rev 2001;(2):CD001738.
50. Kesting MR. et al. Animal bite injuries to the head: 132 cases. Br
J Oral Maxillofoc Surg 2006;44(3):235-239.
51. Cole JK. et al. Early excision and grafting of face and neck bums in
patients tM:T 20 years. Plast Reconstr SU!J 2002;109(4):1266-1273.
52. Bouchard CS, et al. Ocular complications of thermal injury: a
3-year retrospective. J 'ITauma 2001;50(1):79-82.
53. SpencerT, Hall AJ. Stawell RJ, Ophthalmologic sequelae of thermal burns over ten years at the Alfred Hospital. Ophthal Plast
Reconstr Su!J 2002;18(3):196-201.
54. Malhotra R. Sheikh I, Dheansa B. The management of eyelid
burns. Surv Ophthalmol2009;54(3):356-371 .
55. Murphy JV. et al. Frostbite: pathogenesis and treatment. J 1tauma
2000;48(1):171-178.

Michael G. Stewart

Head and neck surgeons are often called upon to manage

penetrating trauma to the face and neck. Knowledge of ballistics, injury patterns, and pertinent anatomy are all essential to the assessment and management of these potentially
serious injuries.
The energy imparted into tissue by a penetrating projectile is determined by its ldnetic energy (KE): KE = 1/2 MV 2,
where M = mass and V = velocity. Since the velocity term
is squared in the equation, high-velocity projectiles can
potentially impart significantly larger amounts of energy
into the tissue impacted. In other words, a projectile with
twice the velocity will have four times the KE of a lowervelocity projectile. However, the actual degree of wounding
will also depend on the energy transfer from the projectile into the tissue ( 1). Typically. firearms are divided into
two groups by their muzzle velocity: low velocity (less than
1,000 ft/s) and high velocity (more than 1,000 ft/s) (2).
Most handguns are low-velocity weapons, with muzzle
velocities between 300 and BOO ft/s. A typical shotgun has
a muzzle velocity of 1,200 ft/s, and a 30-30 rifle has a muzzle velocity of 2,200 ft/s.
Gunshot wounds cause tissue injury by two main mechanisms: direct tissue injury and temporary cavitation. In
the past, there was some consideration about distant injury
from the transmission of shock waves; however, this theory is controversial and has been discounted by many (3).
Cavitation refers to the creation of a pulsating temporary
cavity surrounding the actual bullet path, as illustrated in
Figure 7 6.1. This temporary cavity results in tissue damage and tissue loss adjacent to the missile path. This is an
important concept for the treating physician to understand:
anatomic structures may be significantly damaged by a
gunshot wound without being actually penetrated by the
projectile. Because of their high KE, high-velocity weapon
injuries tend to have greater cavitation and transmission
effects than low-velocity injuries. Clinically. low-velocity
injuries are usually characterized by tissue damage, whereas

high-velocity injuries are typically characterized by tissue

loss. This can be an oversimplification; for example, a highvelocity. high-energy projectile may pass through tissue
and exit with a significant amount of energy remaining. So,
high velocity does not always equal high-energy transfer
and tissue damage.
In addition, bullets or pellets in flight have several components to their rotation, as illustrated in Figure 76.2.
These rotational characteristics increase the potential that a
bullet may take an erratic course after impact, and also may
increase the amount of direct tissue injury (1,3). Further,
projectiles may shatter on tissue impact, resulting in secondary projectiles with the potential for additional injury.
Similarly, impacted bone may also shatter, and secondary
bone fragments may cause further tissue damage.

GENERAL TRAUMA PRINCIPLES

The basic principles of trauma management apply to all
patients with penetrating face and neck trauma. These
trauma principles may be remembered using the mnemonic ABCDE. "N denotes assessment of ai1Way and
cervical spine, B" stands for assessment of breathing, "C"
refers to assessment of circulation, "D denotes assessment
of disability and neurologic status, and "E" stands for exposure
and overall evaluation of the patient for other injuries. The
overall prevalence of cervical spine fracture in patients with
isolated facial trauma is So/o to Bo/o (increasing to as much
as 11 o/o when two or more fractures were present) (4), but
all patients should be considered to have a cervical spine
injury until proven otherwise.
In the emergency center, in addition to cervical spine
x-rays, all patients with penetrating face trauma should
have an AP and lateral skull and face x-ray. These films
can identify remaining bullets, pellets, bullet fragments,
and bony fragments, and may help define the path of the
projectile. In stab wounds where the weapon is still present,

1131

1132

Section V: Trauma
Jemporary cav1ty

FiguN 76.1 Cavitation effects of a bullet wound to soft ti!l9ue.

the depth of penetration may be identified. Furtha;. these

roentgenograms may reveal the presence of subcutaneous
air or ttacheal deviation.
Evaluation of the aiJway should be the first priority in
the emergency center for all patients with penetrating face
or neck trauma. 'Ihe techniques of air:way establishment
are discussed in detail Chapte:JS 63 and 64 of this textbook,
but most patients can be carefully intubated ttansorally; if
a ceM.cal spine injw:y is suspected, the patient may be intubated while continuous in-line neck stabilization is applied.
If the ailway is Wl8table, and there is significant bleeding
or edema in the oral cavity or pharynx. the patient should
undergo cricothyroidotomy or wgent tracheotomy in the
eme~gency center. Blind nasottacheal intubation should be
avoided,. although in the stable patient a fiberoptic-guided
transna.sal approach may be appropriate. In penetrating
injuries to the neck with obvious tracheal injw:y (e.g., sucking wound,. significant subcutaneous emphysema), the trachea may be carefully intubated through the entry wound
itself using an armored/reinforced endotracheal tube.
Once the airway has been stabilized, the remainder of the
examination may be completed, including a areful assessment of entty and exit wounds. When possible, information on the number of stab or gunshot wounds, the type
of weapon. distance from assailant, etc., may be helpful in
wound assessment. In patients with a stable airway, flexible

Figure 76.2 The rotational ballistics of a missile, demonstrating

yaw, precassion, and nutation.

fiberoptic laryngoscopy is a vay helpful part of the ewluation. and helps assess the presence and extent ofhu:yngopharyngeal injw:y.'Ihe physician should be aware that projectiles
and bones may fragment or shattei;. and projectiles may
ricochet and change directions through the tissue-both of
which. may lead to secondary injuries. Probing entty and exit
wounds or removing blood clots in the emergency center
should be avoided,. because this may precipitate significant
bleeding. In addition. all patients with penetrating face or
neck ttauma should be considered for tetanus prophylaxis.

PENETRATING FACIAL INJURIES

.Although much attention has been focused on treatment
algorithms for patients with penetrating trauma to the
neck, chest, and abdomen. there is less written about penetrating injuries to the face. 'Ihe first attempt to create a staging system for penettating facial trauma was made by Gant
and Epstein in 1979 (5) and later demonstrated pictorially
by Gussack and Jurkovich ( 6). The Gant and Epstein system divided the face into entry zones I, II, and Dl, which
was potentially confusing since neck entry zones used the
same nomenclature. Furthet;. zone I was superior to the
suprao:rbital rims-which actually could be considered
a penettating inttacranial (rather than facial) injw:y. The
Gant and Epstein system was modified by Dolin et al. (7)
into entry zones A, B, and C, but the demarcation points
between zones were uncleat and two zones (A and B) actually had similar patterns of injw:y. Subsequently, Chen
et al. (8) attempted to simplify facial zoning by designating two entry zones, "midface and ...mandible (Fig. 76.3).

Figure 76.3 Midfac:e and mandible zoncas for penetrating inJu

ries to the face. Reprinted from Chen AY, Cit al. Pcanetnrtfng lnJurlcas
of the face. Ototaryngot Hetld Neck. Surg 1996;115:464-470, with
permission. Copyright 1996 by C.V. Mosby Year Book, Inc.

Chapter 76: Penetrating Face and Neck Trauma

injuries, the wadding" material &om the shotgun shell

may become imbedded into the soft tissue, and must be
thoroughly removed to avoid subsequent problems with
infection.
In one series ( 8 ), all patients with shotgun wounds to the
face invariably had pellet penetration of both midface and
mandible entry zones, so the zoning system was not helpful in predicting injw:ypattcrn. Therefore, shotgun woWlds
should probably be considered as a separate group. This
high prevalence of ocular injw:y has been noted in other
series as well (9,10). Shotgun wounds to the face also have
a relatively high prevalence of globe injury, so careful ophthalmologic assessment is important. Shotgun WOWlds to
the face may also cause facial fracture or vascular injw:y, or
rarely may achieve intracranial penetration.

1: EVALUATE AIRWAY

AIRWAY INADEQUATE?

AIRWAY ADEQUATE?

then

Consider elective airway establishment

(preferably oral intubation)!.!:

1) GSW with mandible entry

2) bleeding or edema in oral cavity
3) dose-range SGW

then

Establish emergency airway

II: COMPLETE EVALUATION: BREATHING, CIRCULATION,

CERVICAL, SPINE, EYE EXAM

Ill: EVALUATE PATH OF BULLET

ENTRY AND EXIT WOUNDS?

then

NO EXIT WOUND?

then

Clinical assessment of path

INTRACRANIAL
PENETRATION?
then

Neurosurgery
oonsultation

SHOTGUN OR
STAB INJURY?

then

Arteriogram

Stab Wounds

then

Facial X-ray (AP and lateral) to

p t e bullets/pellets

PROXIMITY TO MAJOR OCULAR INJURY?

VASCULAR STRUCTURE?
then

Ophthalmology
consultation

1133

FACIAL
FRACTURE?
thon

Complete facial
series /scan face

Figure 76.4 Algorithm for 1hca Initial managcamcant of patlcants

with penetrating lnjurlcas to thCI face. Reprinted from Chen AY.
et: al. PcanCitratfng Injuries of thCI face. Otolaryngol Head Nedc
Surg 1996;115:464-470, with ptarmlsslon. Copyright 1996 by C.V.
Mosby YCI8r Book, Inc.

Injw:y patterns to these zones are distinct. and the system

iJ easy to remember. An algorithm for the care of patients
with penetrating facial trauma is depicted in Figure 76.4.

Shotgun Injuries
It iJ important to remember that shotguns have fairly high
muzzle velocity, and dose-range shotgun injuries may
impart significant KB to facial tissue. Recognizing that the
diJtance &om weapon to victim was a key point in shotgun
injuries, an early classification system classified shotgun
injuries into three groups: long-range injuries (type 1more than 7 yards distance between weapon and victim)
were characterized by subcutaneous or deep fascia injuries
only, medium-range injuries (type II-3 to 7 yards distance) were characterized by injuries to structures deep to
the deep fascia. and dose-range injuries (type III-under
3 yaids diJtance) typically created massive tissue destruction. Currently, trauma swgeons usually divide shotgun
wounds into only two groups: close range and long range
(9). The concept iJ the same: dose-range injuries have
ver:y high kinetic injw:y and behave similarly to highvelocity rifle injuries. In addition, in dose-range shotgun

Stab wounds to the face may result in globe injury, vascular

injw:y, and even intracranial penetration. If the weapon is
still in place, AP and lateral skullx-rays can help predict the
depth of penetration and direct further evaluation. Many
authors have noted that in cases where the lmife or weapon
is still in place, it is important to not remove or dislodge it,
since it may be providing tamponade of injured vascular
structures. Rathe~;. the patient should be taken for angiography with the protruding weapon in place. If major vascular
injw:y is identified, intravascular balloons may be placed
by the inteiventional radiologist (or proximal vessels may
be isolated by the swgeon), and the weapon may then be
removed under controlled ciralmstances in the operating
room (11).

Gunshot Wounds
The midfacefmandible zoning sy3tem is particularly
applicable for gunshot injuries to the face, since the two
entry zones have distinct patterns of injwy. Gunshot
woWlds to the midface have a high prevalence of vascular
injury, globe injury, intracranial penetration, and facial
fracture requiring open reduction and internal fixation
(8,10,12).
The indications for vascular evaluation in penetrating
wounds to the face can be remembered as the two '"P"s:

1. Proximity to a major vascular structure

2. Penetration posterior to the mandibular angle plane

(MAP).
If the path of a penetrating projectile traverses near a
major vascular structure, vascular evaluation is indicated.
This may be difficult to assess because the path of a projectile after tissue penetration is not always predictable,
and due to cavitation, the bullet may be somewhat distant from the vessel and still cause a significant injucy.
A useful anatomic landmark is the MAP as described by
Gussack and Jurkovich (6). The .MAP is an imaginary

1134

Section V: Trauma

Mandibular
angle plane

t:::1.:.___ (map)

Figure 76.5 Lateral view of the face demonmatfng the

Mandibular Angle Plane (MAP).

vertical coronal plane at the level of the angle of the

mandible (Fig. 76.5) and penettation of a projectile or
weapon posterior to this plane is an indication for vascular evaluation. The appropriate radiologic test depends
on the situation. and this point is discussed later in the
chapter.
Gunshot injuries to the mandible entry zone often
require emergency establishment of an airway because
of bleeding, edema, or hematoma formation in the oral
cavity or pharynx (8,12). Although these patienta may
appear initially to have a stable airway, they can quickly
decompensate and require an eme:rgency airway. Although
more common with mandible entry, patienta with midface
gunshot wounds may also require an emergmcy airway
(8,10,12). Therefore, a high index of suspicion and early
elective airway establishment are important in patients
with gunshot wounds to the face.
The computed tomography (CI') scan has significantly
changed the management of penettating facial injuries.
Although airway establishment. hemodynamic stabilization. treatment of other serious injuries, and vascular
evaluation should take precedence, axial and coronal cr
scans of the face often significandy aid the head and neck
surgeon in the assessment of damage, and improve treatment planning. In addition. cr scans dearly demonsttate
the extent and severity of bony fractures.

Management of Specific Injuries

Facial Nerve Injury
Patients with penetrating facial trauma and immediate paralysis of one or more branches of the facial nerve
are likely to have transection of the nerve. If their medical condition permits, these patients should unde:rgo
local exploration with primary nerve repair or nerve grafting, if the wound is lateral to the lateral canthWI. Nerve

injuries medial to the lateral canthWI are typically not

explored because nerve regeneration is usually adequate.
Branches to the forehead and ramus mandibularis should
be repaired because cross-innervation to these areas
is poor, branches to the midface may recover function
through cross-innervation even if completely tmnsected
(12, 13). Severed distal branches retain electrical excitability for about 48 hours, and a ner:ve stimulator may be
used intraoperatively. Howevet it is common that patients
have other medical issues which delay facial nerve exploration and repair, and that is acceptable since the results
after cable graft are not dependent on time of repair (12).
The preferred neurorrhaphy technique is to trim back the
perineurium away from the anastomosis and perform epineurial repair with 9-0 or 10-0 monofilament suture (13).
Facial nerve injuries which progress from partial to total
paralysis following injw:y, or paralysis which develops several hours after injury, are Wlually secondary to edema and
may be treated expectandy.

Parotid Duct Injury

Wounds to the cheek below the zygomatic arch, which
injure the buccal branch of the facial nerve are also likely to
injure the parotid duct. If parotid duct injw:y is suspected
(e.g., clear saliva draining &om a penetrating cheek wound,
or sialocele formation), the wound should be explored
and the duct primarily repaired over a stent

Facial Bone Fracture

1hese injuries are disalSsed in more detail in other
chapteD. Not all facial fractures will require open reduction
internal fixation, but many will (10). Some &ac:tures will
require debridement only, or can be managed with closed
reduction.

Complications
Even without intracranial penetration or major vascular
injury, penettating wounds to the face have the potential for early and late complications in 15% to 35% of
patients. Potential complications are listed in Table 76.1.
While some are directly attributable to the injw:y-such
as blindness or facial nerve injw:y-some complications
are potentially preventable with early recognition and
aggressive management In particul~ nasal obstruction
and synechia, sinusitis, and choanal stenosis may be prevented with intranasal debridement. placement of nasal
stents, and the techniques of functional endoscopic sinonasal surgery to restore adequate sinus drainage. In addition. diplopia and orbital or periorbital infections may be
prevented with careful reconstruction of the Oibital floor
to restore o:rbital anatomy and isolate the maxillary sinus
from the orbital contents. Furtha;. trismus and malocclusion may be prevented with adequate maxillomandibular
:fixation. and early mobilization and stretching of the temporomandibular joint

Chapter 76: Penetrating Face and Neck Trauma

1135

II COMPUCA110NS
PENE1RA11NG FACE
AND NECK INJURIES
~

Facial injuries
Blindnea
Visual loss
Diplopia
Facial nerve paralysis
Cerebrospinal fluid leak
Soft 1i55ue lo55
Bony malunion
Malocclusion
Tri5mus
Orbital/periorbital cellulitis
Sinusitis
Oral-antral fistula
Nasal obstruction/stenosis
Choana! stenosis

Nedc: injurie$
Airway obstruction
Pharyngocutaneous fistula
Nec:k abscess
Mediastinitis
Voc:al c:ord paresis
Cervical spine osteomyelitis

PENETRATING NECK INJURIES

1he complex anatomy of the neck requires careful assessment of missile trajectory and site ofentry. The neck can be
divided into two triangles using the sternocleidomastoid
muscle (Fig. 76.6). The anterior ttiangle contains most of
the major anatomic structures of the neck: the laJ:)'IU. trachea. pharynx. esophagus, and major vascular structures.
The major structures of the posterior triangle are muscles,
the spinal accessoty nerve, and the spinal column. The platysma muscle lies just deep to the skin of the neck only
in the anterior triangle. WoWlds which penetrate the platysma have the potential for serious injw:y; wounds, which

Omoclavicular

Figure 76.6 Aniii:Omlc triangles of the nc~dc the neck Is dMded

Into anterior and posterior triangles by the stQrnocleldomast:old
muscle.

do not penetrate the platysma are superficial by definition,

and do not require further evaluation.
The neck has been divided into three entry zones
(Fig. 76.7). Zone I comprises the lower neck below the
inferior bolder of the aicoid cartilage. Zone II consists of
the neck between the angle of the mandible and the inferior bolder of the cricoid cartilage, and zone DI comprises
the neck superior to the angle of the mandible up to the
skull base. Zone D is the largest zone and the most common site of entry in penetrating neck trauma (14,15).
McConnell and Trunkey combined the results of 16 huge
series and foWld that the most commonly injured structures in the neck were the larynx and trachea (considered as

Figure 76.7 Horizontal entry zones of th"

neck for pencrtrlrtlng Injuries to thQ neck.
Modified from Jurkovich GJ. In: Moore EE,
ed. Thenedc:. Toronto: Becker, 1990:126.

1136

Section V: Trauma

PENETRATING NECK TRAUMA

lD DIAGNOSIS
Diagnosis

Signs and Symptoms

Tests

Vascular injury

Shock
Hematoma
Hemorrhage
Pulse deficit
Neurologic deficit
Bruit or thrill in neck
Subcutaneous emphysema
Airway obstruction
Sucking wound
Hemoptysis
Dyspnea
Stridor
Hoarseness or dysphonia
Subcutaneous emphysema
Hematemesis
Dysphagia or odynophagia

Angiogram
CT angiogram
Doppler ultrasound
Neck exploration

Laryngotracheal injury

Pharynx/esophagus injury

a group: 10% of patients), and the pharynx and esophagus

(considered as a group: 10% of patients). The most common vascular structures injured were the internal jugular vein (9%), the internal and common carotid arteries
(7%), the subclavian artery (2%) and the external carotid
artery (2%). The vertebral artery was injured in only 1% of
patients in the combined review.
The overall mortality rate for penetrating neck trauma
at most major centers is 3% to 6% (14,16). The major
cause of death in patients with penetrating neck trauma is
exsanguinating hemorrhage from a vascular injury. Other
causes include spinal cord injury, cerebral ischemia, airway obstruction, air embolism, and pulmonary embolism.
Most series report at least some mortality from missed
esophageal injuries, which usually manifest as sepsis.
A careful clinical exam is often an accurate predictor of the
extent ofinjury. The clinical signs and symptoms ofsignificant
neck injury are listed in Table 76.2. Of course, patients with
refractory shock, uncontrollable hemorrhage, or evolving
neurologic defidt should undergo immediate neck exploration (Table 76.3). The surgeon should be prepared to control
and repair major injuries to the carotid artery or jugular vein.
Patients who are clinically stable but have signs or symptoms
of injury to a major neck structure should undergo directed
evaluation with subsequent repair of injured structures. The
management of the asymptomatic patient with penetrating
neck trauma is controversial, however.
Traditionally, all patients with penetrating neck wounds,
which penetrated the platysma-whether symptomatic or
not-underwent neck exploration. The rationale was that
the sensitivity of neck exploration was high, and the morbidity of the surgery itself was low. whereas the morbidity
of a missed injury was potentially fairly high. When mandatory neck exploration was performed, negative exploration

Laryngotracheoscopy
Neck exploration
CT scan

Contrast esophagogram
Esoph agoscopy
Neck exploration

rates of 30% to 50% could be expected. In the 1980s and

1990s as imaging and flexible endoscopic technology
advanced, trauma surgeons began using serial examinations and evaluations in selected neck injuries-based on
zone and clinical presentation (16). In addition, many
vascular injuries are now amenable to definitive endovascular treatment by the interventional radiologist. There is
good evidence that directed examination with observation
and serial examinations may be as effective as mandatory
exploration in selected patients (16,17); these issues will be
discussed further below. An example of a simplified protocol for penetrating neck trauma is depicted in Figure 76.8.
As in penetrating injuries to the face,. the mechanism of
injury is important for the treating physician to consider.
Although the depth of penetration of stab wounds may be
difficult to assess, stab wounds tend to injure only the tissue directly penetrated. Gunshot wounds, however, may
cause significant tissue loss as well as damage to adjacent
structures because of cavitation and the high energy of the
projectile.

EMERGENCIES
PENETRATING FACE
AND NECK INJURIES

Diagnosis

Emergency

Vascular injury

Hemorrhage
Neu ro logic deterioration
Airway compression
Airway obstruction
Pneum omedi asti num
Pneumothorax

Larynx or tracheal injury

Chapter 76: Penetrating Face and Neck Trauma

Active hemorrhage
Airway compromise
Shock, hemodynamic
compromise

Zone

1137

IMMEDIATE
NECK EXPLORAllON

I~

VASCULAR
EVAWAllON

VASCULAR
INTERVENTION
(lntravaacular v.
open)
OBSERVAllON

PENETRATING
NECK

Stable with symptoms

(i.e., hematoma,
subcutaneous
Emphysema)

WOUND
Airway,
breathing,
circulation
Phylcal exam

Zone

11---------------;~

VASCULAR
EVALUATION
ESOPHAGEAL
EVALUATION

NECK EXPLORATION
VASCULAR
INTERVENllON .OS
NECK EXPLORATION
NECK EXPLORATION

Zone

I~

Stable with no
symptoms

... DIRECTED EXAM: Vacular evaluation, esophageal evaluation

andlor laryngocopy based on projectile path and clinical exam

VASCULAR
EVALUATION

DIRECTED EXAM,..

VASC. INTERVENTION
OBSERVAllON
NECK EXPLORATION
OBSERVATION

VASCULAR
EVALUAllON
ESOPHAGEAL
EVALUAllON

VASCULAR
INTERVENTION QB
NECK EXPLORATION
OBSERVAllON

Figure 76.8 An example algorithm for the initial management of patients with penetrating injuries
to the neck. Modified from Mansour MA. et al. Validating the selective management of penetrating
neck wounds. Am J Surg 1991 ;162:517-521, Copyright 1991 by Excerpta Medica, Inc.

Zone I Injuries
Penetrating injuries which enter zone I of the neck are
potentially lethal because of the potential for injury to the
great vessels of the neck and mediastinum, as well as the
cervical and thoracic esophagus. Most trauma centers advocate routine vascular evaluation of the aortic arch and great
vessels, along with an esophageal evaluation-whether
or not the patient is symptomatic, since up to one-third
of patients with a clinically significant zone I injury may
have no symptoms at presentation. Mandatory esophageal
evaluation is also recommended because a missed zone
I esophageal injury is potentially different from a missed
zone II injury. An esophageal or pharyngeal injury in zone
II will usually develop clinical signs or symptoms (such as
subcutaneous emphysema) within a few hours, and overall morbidity and mortality may not be affected. A missed
esophageal injury in zone I, howeve~; may be clinically
silent until mediastinitis and sepsis develop.
Opinions on the ideal diagnostic test for the esophagus
and pharynx differ, and the options include endoscopy,
contrast esophagram using barium or gastrografin, or cr

scan. If a contrast esophagram is used, there is also a question about which contrast medium to use. Barium-based
contrast is thicker, and if a penetrating injury is present. the
barium is more likely to demonstrate it. However ifbarium
leaks into the tissues of the neck, there is significant risk of
infection. Gastrografin (meglumine detrizoate) is a thinner
contrast material, and is less likely to promote infection
if leaked into the neck, but many feel it is a poorer agent
because smaller injuries can be missed. One potential solution is to first study with gastrografin. If there is a large
leak. then the diagnosis is made. If there is no leak. then do
a second study with barium-to ensure there is not even a
small leak. A different option is to use '"thin barium,~ or
dilute barium as the initial evaluation.
Studies on the sensitivity and specificity of radiologic
tests to detect pharyngeal or esophageal injury have reported
as high as 9 0% to 100 o/o ( 18, 19). Similarly, flexible or rigid
esophagoscopy both have high specificity and sensitivity
(19), so the method can be chosen based on operator preference. Some have noted that in all cases of penetrating
injury, at least one of the diagnostic tests-rigid or flexible

1138

Section V: Trauma

esophagosoopy, or barium swallow-demonstrated the

injury ( 18). Therefore a combination of those tests should
not miss an injury.
Another option for assessment is the cr scan (20,21).
cr scans have been found to be very helpful in determining the path of the projectile (using the tract of air bubbles,
damaged tissue, or projectile particles), which then helped
guide decision making for further evaluation and treatment. In fact. in one study additional radiologic imaging
and surgery were avoided in some patients (21).

Zone II Injuries
As previously discussed, patients with penetrating zone

II injuries who are symptomatic should undergo neck

exploration. Asymptomatic patients with penetrating zone
II injuries may be treated with either mandatory exploration or directed evaluation and serial examinations
(16, 17,19). In earlier decades, mandatory neck exploration was the standard of care, and many negative explorations were acceptable. Howev~ several prospective studies
have shown that careful observation (with radiologic and
endoscopic evaluation) of the asymptomatic zone II injury
is an effective protocol. Patients usually underwent some
additional evaluation, such as cr scan, vascular evaluation, or flexible endoscopy, and also serial examinations.
If patients developed findings of injury, such as subcutaneous emphysema. they were then taken for surgical exploration and repair. Studies have shown that the observed
patients did very well as a group, with virtually no missed
injuries, morbidity. or mortality, and perhaps a shorter
average length of stay than patients who underwent exploration. In another study, physical examination aloneusing defined criteria for a positive examination-was
shown to have high sensitivity (93%) and negative predictive value (97%) when used for the assessment of potential vascular injury (22).
However. these protocols require frequent availability
of additional testing. and serial examinations. So in some
centers, surgical exploration might be a more appropriate plan for asymptomatic penetrating zone II injuries. In
additio~ some surgeons still prefer mandatory exploration
over observation and selective exploration. citing the prevalence of previously undetected injuries when mandatory
exploration is performed. Others note, however. that many
of those injuries (e.g., small vascular injuries) might never
have caused a problem if simply observed.
In summary, asymptomatic patients with penetrating
zone II injuries may be treated with either mandatory neck
exploration, or directed evaluation and serial examinations. However, a treatment protocol utilizing observation
with serial examinations requires adequate physician manpower as well as a 24-hour facility prepared for emergency
testing and surgery at any time. Early neck exploration with
prompt discharge home for negative explorations is an
efficient and time-tested method of managing penetrating

zone II injuries, and in some settings, may be preferred

over multiple tests and observation.

Zone Ill Injuries

Penetrating injuries to zone III have the potential for
injury to major blood vessels and the cranial nerves near
the skull base. Some patients with arterial injuries may be
asymptomatic at presentation, and surgical exposure and
control of bleeding in this location may be quite difficult.
In addition, many vascular injuries are amenable to definitive treatment by an interventional radiologist Therefore,
the injury can be potentially treated in the same setting
as the diagnostic angiogram. Although vertebral artery
injury appears to be relatively rare, this may be the result of
infrequent use of four-vessel angiography in many series.
Therefore, the benefit of routine four-vessel angiography is
not dear. Certainly, however, if the bullet path is near the
vertebral column, the vertebral arteries should be imaged.

Vascular Evaluation in the Head and Neck

As the speed of scanners and resolution of images have

improved, the recommended protocols for vascular evaluation have also evolved. The American College of Radiology
recommendations note that formal catheter angiography.
cr angiography. MR angiography. and color Doppler
ultrasound could all have a role in vascular evaluation of
the head and neck (23). However, cr angiography and
catheter angiography are the most practical, with the highest level of recommendation (23). The resolution of multidetector cr angiography is excellent, and the evaluation is
quite sensitive, even to small intimal injuries-sensitivity
is 90% to 100%, specificity is 94% to 100%, and positive and negative predictive values are 93% to 100% and
98% to 100%, respectively (24). Furthermore, the speed
of modem scanners means that the scan can be quickly
completed and processed. In addition, the soft tissue cr
data is also very useful in evaluation of the penetrating
neck injury. So cr angiography can yield very valuable
information. However, obviously, Cf angiography does
not allow intervention if an injury is discovered. Catheter
angiography does allow for both diagnostic assessment
and endovascular intervention if needed. However. catheter angiography is more invasive, has the potential for
increased complications at the catheterization site and
intracranially, and it requires the presence of an interventional radiologist And, in many cases of penetrating
trauma. no intervention will be required. So, the selection between high-resolution cr angiography and catheter
angiography could be based on clinical suspicion ofvascular injury, with high-probability injuries going directly to
catheter angiography-as one potential strategy. However.
as discussed earlier, many patients with vascular injury are
asymptomatic, so making this clinical distinction could be
difficult. Finally, color Doppler ultrasound has excellent

Chapter 76: Penetrating Face and Neck Trauma

resolution and sensitivity, but it is highly operator dependent,. cannot be automated, and cannot be reliably used
in certain situations when there is bone or air in the intervening space. And of course. no intervention can be performed. So, under certain situations it can be quite useful,
but it is not a widely used modality.

Management of Specific Injuries

Vascular Injuries
As noted earlier, blood vessels are commonly injured in
penetrating neck trauma. Whenever possible. primary
repair of the injured vessel is ideal. The value of arterial
repair in the face of focal neurologic deficit or coma is controversial, but most vascular surgeons tend to favor revascularization in cases of traumatic vascular injury (15). In
any event. the assistance of an experienced vascular surgeon is strongly recommended in these cases.
Laryngotracheal Injuries
The management of penetrating injuries to the larynx has
been well described by Schaefer (25) and is covered in this
textbook. in Chapter 77. If the thyroid or cricoid cartilage
has been damaged and is unstable. open repair with internal fixation is recommended. If the cartilage is calcified, 1.0
or 1.3 mm bone plates and screws may be used; if the cartilage is not fully calcified, wires and bolsten; can be used
as described by Austin (26). If the endolaryngeal mucosa
has been significantly disrupted, tracheotomy with midline thyrotomy and direct repair of mucosal injuries with
small absorbable sutures is used. Endolaryngeal stents are
seldom used in penetrating trauma because the structural
framework of the larynx is usually intact (unlike in blunt
trauma), although stents may be used if the anterior commissure has been injured.
Tracheal injuries are managed with either tracheotomy
through the injury or direct closure. Stab wounds can typically be dosed primarily in two layen;: an inner layer of
absorbable suture incorporating the mucosa (with the
knots on the outside of the lumen) and an outer layer of
permanent suture securing cartilage ring to cartilage ring
in a submucosal plane. Patients are usually kept intubated
for 2 to 3 days, then extubated under controlled circumstances. Gunshot wounds to the trachea may result in tissue loss, which may compromise the safety of primary
closure since minimal tension at the suture line is a key
component of successful tracheal repair. Once the wound
edges have been debrided, superior or inferior tracheal
release techniques may be necessary to achieve a tensionfree closure.
Pharynx and Esophageal Injuries
Missed injuries to the pharynx and esophagus are a significant source of morbidity and mortality in penetrating
neck trauma. All patients with clinical signs or symptoms of pharynx or esophagus injury (e.g., subcutaneous

1139

emphysema, hematemesis, hypopharyngeal blood, etc.)

should undergo neck exploration. Intraoperative esophagoscopy may be helpful in identifying the location of
pharyngeal or esophageal penetration, especially in stab
injuries. In addition, instillation of saline. methylene
blue, or air into the pharynx and esophagus can assist in
injury location.
However, up to 50% of patients with pharyngeal and
esophageal injury may be asymptomatic at presentation.
In an asymptomatic patient. if injury is suspected based
on missile trajectory. the combination of esophagoscopy
and contrast esophagography is probably most sensitive at
detecting injury.
Esophageal injuries should be dosed directly; if not, the
saliva leak is a significant cause of morbidity and mortality.
In fact,. delay in exploration and repair beyond 24 hours
after injury has been associated with poorer outcome in
many studies. In earlier literature. the cervical esophagus
and hypopharynx have been grouped together and considered as a unit. However, there is evidence that hypopharyngeal injuries may not always require direct closure (27,28);
this is similar to oropharynx injuries.
Penetrating injuries to the hypopharynx, which are
superior to the level of the arytenoid cartilage may be
treated somewhat differently than hypopharyngeal injuries inferior to the level of the arytenoids (2 7). Primary
closure is not always necessary in penetrating injuries to
the upper hypopharynx; patients may be treated with parenteral antibiotics, and kept without oral intake for 5 to
7 days. Injuries to the hypopharynx inferior to the level
of the arytenoid cartilage (e.g., in the dependent portion
of the hypopharynx. where saliva and secretions tend to
pool) should be treated with exploration and primary
watertight closure using absorbable suture with drainage of
the adjacent neck space. The patient should be kept NPO
while the repair heals-typically 5 to 7 days. Injuries to the
cervical esophagus should be treated similar to those of the
inferior hypopharynx. with watertight closure and drainage. External drainage and bypass procedures (e.g., cervical pharyngostomy) should generally be avoided, although
with severe injuries and tissue loss, diversion procedures
may play a role.

Complications
The complications of penetrating neck injuries are listed
in Table 76.1. Most complications are directly attributable to the injury itself, but some are potentially preventable. The potentially preventable injuries (such as neck
abscess, pharyngocutaneous fistula, etc.) are usually due
to missed or delayed diagnoses, so the best way to avoid
these complications is to be thorough and vigilant in the
initial evaluation for injuries and the immediate followup period after treatment. Although less common than
50 years ago, the mortality of penetrating neck trauma
remains 3% to 6%.

1140

Section V: Trauma

Patients with penetrating trauma to the face and

neck should undergo systematic evaluation using
the ATLS protocol (..ABCDE"). Airway establishment is the first priority, particularly in gunshot
wounds to the mandible and midface zones.
High-velocity gunshot wounds have high KE, and
tend to cause tissue loss and secondary injuries.
Close-range shotgun wounds have high KE, and may
cause massive tissue destruction. Always remove the
wadding" material from soft tissues in dose-range
shotgun wounds.
Shotgun wounds to the face have a high prevalence
of globe injury. Gunshot wounds to the midface may
cause injury to the globe, may injure major vascular
structures, or may achieve intracranial penetration.
The indications for arteriogram in penetrating facial
wounds are (a) proximity to a major vascular structure or (b) penetration posterior to the MAP.
Classification of penetrating neck wounds into entry
zones I, IL and III helps to direct management.
Injuries that penetrate the platysma have the potential to damage important neck structures. Most of the
vital structures of the neck are in the anterior neck.
Bleeding, expanding hematoma, shock, and evolving neurologic deficit suggest vascular injury.
Subcutaneous emphysema, dyspnea, airway
obstruction, hoarseness, or stridor suggest laryngotracheal injury.
Subcutaneous emphysema and dysphagia suggest pharyngoesophageal injury. but up to 50% of
patients will have no clinical signs of injury.
Patients with symptoms of injury to important neck
structures should undergo neck exploration, except
stable patients with zone I or zone III injuries; preoperative vascular evaluation and esophageal evaluation may help direct the surgical approach, or may
identify vascular lesions amenable to treatment by
the interventional radiologist.

REFERENCES
1. Bartlett CS, Helfet DL. Hausman MR. et al. Ballistics and gunshot
wounds: effects on musculoskeletal tissues. J Am Acad Orthop

SulK 2000;8:21-36.
2. Volgas DA. Stannard JP. Alonso JE. Ballistics: a primer for the
surgeon. Injury 2005;36:373-379.

3. Fackler ML. Civilian gunshot wounds and ballistics: dispelling

the myths. Eme'K Med Clin North Am 1998;16:17-28.
4. Mulligan R, Mahabir R. The prevalence of cervical spine injury.
head injury, or both with isolated and multiple craniomaxillofacial fractures. Plast Recorutr SUJK 2010; 126:1647-1651 .
5. Gant ID, Epstein LI. Low-velocity gunshot wounds to the maxillofacial complex. J 'ITauma 1979;19:674-677.
6. Gussack GS, Jurkovich GJ. Penetrating facial trauma: a management plan. SouthMedJ 1988;81:297-302.
7. Dolin J, Scalea T, Mannor I.. et al. 1he management of gunshot
wounds to theface. JThmma 1992;33:508-515.
8. Chen AY, Stewart MG, Raup G. Penetrating injuries of the face.
Owla1}'Tigol Head Neck SUTK 1996;115:464-470.
9. Vayvada H, Menderes A. Y1lmaz M, et al. Management of
dose-range. high-energy shotgun and rifle wounds to the face.
J Craniofac SulK 2005;16:794-804.
10. Hollier I.. Grantcharova EP. Kattash M. Facial gunshot wounds: a
4-year experience. J Oral Maxillofac Surg 2001;59:277-282.
11. Meer M, Siddiqi A. Morkel JA. et al. Knife inflicted penetrating
injuries of the maxillofacial region: a descriptive, record-based
study. Injury 2010;41:77-81.
12. McLean JN, Moore CE, Yellin SA Gunshot wounds to the faceacute management. Facial PlastSurg 2005;21:191-198.
13. Coker NJ, Management of traumatic injuries to the facial nerve.
Otola1}'Tigol Clin North Am 1991;24(1):215-227.
14. McConnell DB, Trunkey DD. Management of penetrating trauma
to the neck. Adv SUTK 1994;27:99-119.
15. Thompson BC, Porter JM, Fernanda LG. Penetrating neck
trauma: an overview of management. J Oral Max~1lofac SulK
2002;60:918-923.
16. Scott BG. Approaches to penetrating injuries of the neck.
In: Stewart MG, ed. Head, facrs, and neck trauma: comprehensive management. New York: Thieme Publishers, 2005:
202-206.
17. Kesser BW, Chance E, Kleiner D, et al. Contemporary management of penetrating neck trauma. Am Surg 2009;75:1-10.
18. Weigelt JA. Thal ER, Snyder WH, et al. Diagnosis of penetrating
cervical esophageal injuries. Am J SulK 1987;154:619-622.
19. Bagheri SC, Khan HA. Bell RB. Penetrating neck injuries. Oral
Maxillofac SUlK C1in NorthAm 2008;20:393-414.
20. Vassiliu P, Baker J, Henderson S, et al. Aerodigestive injuries of
the neck. Am SulK 2001;67:75-79.
21. Gracias VH, Reilly PM, Philpott J, et al . Computed tomography in the evaluation of penetrating neck trauma. Arch SulK
2001;136:1231-1235.
22. Azuaje RE, Jacobson LE, Glover J, et al . Reliability of physical
examination as a predictor of vascular injury after penetrating
neck trauma. Am SulK 2003;69:804-807.
23. American College of Radiology. ACR Appropriateness Criteria,
updated 2009. Accessed through www.acr.org. Mart:h 26, 2011 .
24. Schroeder Jw. Baskaran V. Aygun N. Imaging of traumatic arterial injuries in the neck with an emphasis on CfA. Em~J1K Radio!
2010; 17: 109-122.
25. Schaefer SD. The acute management of external laryngeal
trauma. A 27-year experience. A"'h Otola1}'Tigol Head Neck SulK
1992; 118:598-604.
26. Austin JR. Stanley RB, Cooper DS. Stable internal fixation of
fractures of the partially mineralized thyroid cartilage. Ann Otol
Rhino! Laryngol1992;101:76-80.
27. Fetterman BL, Shindo ML, Stanley RB, et al. Management of
traumatic hypopharyngeal injuries. Laryngoscope 1995; 105:
8-13.
28. Stewart MG. Pharyngeal trauma. In: Stewart MG, ed. Head, face,
and neck trauma: comprehensive management. New York: Thieme
Publishers, 2005:223-230.

/. Randall Jordan

Byron K. Norris

Laryngeal trauma is a relatively uncommon event requiring

timely, proper management of injwy to preserve the
patient's life, airway, and voice (1). Each case of external
laryngeal trauma presents a unique set of problems, but
despite the diversity of injuries, specific management
guidelines can be applied. Adhering to such an approach
assists in attaining the best possible outcome after blunt
or penetrating external laryngeal trauma. Severity of injwy
and delay in treatment correlate with poor outcome.

PATHOPHYSIOLOGY OF LARYNGEAL
INJURIES
Blunt Trauma
Blunt trauma to the larynx is caused mainly by motor
vehicle accidents including all-terrain vehicles, personal
assaults, or sports injuries. Although the mandible and
sternum normally protect the larynx,. the neck can be
hyperextended during the trauma, which allows the laryngeal skeleton to be crushed between the impinging object
and the cervical vertebral column. With a moderate blow
to the larynx,. the momentum of the vocal folds causes a
shearing effect between the vocalis muscle and the internal perichondrium. This results in injuries such as endolaryngeal mucosal tears, edema, or hematoma. More severe
trauma produces fractures of the laryngeal cartilages and
disruption of the laryngeal ligaments.
Subluxation or dislocation of the arytenoid cartilage can
produce an immobile vocal fold. Unilateral injwy to the
recurrent laryngeal nerve often is associated with cricoarytenoid joint injuries owing to the proximity of the recurrent laryngeal nerve to the cricoid cartilage. Fractures of
the cricoid cartilage can occur alone or with other injuries,
especially after lower cervical trauma. As the only complete
ring of the airway, structural integrity of the cricoid cartilage is essential in airway maintenance.

Scott P. Stringer

The so-called clothesline injwy that occurs in

association with blunt laryngeal trauma deserves special
attention because of its severity. This injwy typically occurs
when the neck of an individual (typically an adolescent
or young adult) riding a motorcycle, all-terrain vehicle. or
snowmobile strikes a stationary object such as a wire fence
or tree limb. The transfer of such a large amount of force
confined to a relatively small area of the neck crushes the
laryngeal cartilages and commonly causes cricotracheal
separation. The airway is held together precariously by
the intervening mucous membrane and pretracheal fascial sleeves. Bilateral injwy to the recurrent laryngeal nerve
often is associated with cricotracheal separation.
Associated structures also can be injured during blunt
cervical trauma Fractures of the hyoid bone and associated epiglottic injuries can cause airway obstruction. The
greater or lesser cornu of the thyroid cartilage can lacerate
the pharyngeal mucosa as it is pressed against the cervical vertebrae. Sex. and age differences among adults have
been hypothesized as leading to different types of injuries
after blunt trauma. Women are considered more likely to
incur supraglottic injuries than are men because they have
long, thin necks. Elderly persons have been described as
being at higher risk of sustaining comminuted laryngeal fractures than are younger adults because older persons have increased ossification of the laryngeal cartilage.
Neither of these hypotheses has been verified with clinical
observation (2).
Blunt trauma tends to affect the larynx of a child differently from that of an adult. The larynx in children is
situated higher in the neck and is better protected by the
mandible than it is in adults {3). While laryngeal fractures
are less common in children, the incidence is increasing
paralleling the incidence of motor vehicle collisions (4).
Pediatric injuries tend to be less severe than adults due to
the elasticity of the pediatric cartilaginous skeleton; however, the lack of extensive fibrous tissue support and the

1141

1142

Section V: Trauma

relatively loose attachments of the mucous membranes

increase the likelihood of soft tissue damage in children,
and may account for the poorer prognosis of those with
more severe injuries (5,6). Additionally, relatively innocuous trauma may precipitate airway distress secondary to
the small laryngotracheal diameter in children (6). Several
cases of membranous rupture of the pediatric trachea due
to seemingly minor blunt cervical injury have also been
reported (7).
Manual strangulation or hanging-type injuries produce
different patterns of laryngeal injury because the applied
force is fairly static and oflow velocity. This can cause multiple cartilaginous fractures without immediate mucosal
laceration, submucosal hematoma, or marked displacement of the fractures (8).

Penetrating Trauma
Knife and gunshot wounds are primarily responsible for
penetrating trauma. Injuries vary from minor lacerations
to severe disruption of the cartilage, mucosa,. soft tissue,
nerves, and adjacent structures. Gunshot wounds are more
likely than knife wounds to be associated with severe tissue
damage, and high-velocity projectiles cause greater tissue
destruction and wound contamination than low-velocity
projectiles (9). Knife wounds cause less peripheral soft tissue damage than gunshot wounds and are cleaner, but it
is difficult to determine depth of penetration. Injuries to
deep structures, such as the thoracic duct, cervical nerves,
great vessels, and viscera,. can occur well away from the
entrance wound. Death from penetrating trauma may be
caused by complete disruption of the larynx, massive soft
tissue edema, or associated neurovascular injuries. Most
injuries to civilians from penetrating trauma tend to be
limited to the path of the missile because they are caused
by lower-velocity bullets or stabbing (9).

DIAGNOSIS AND EVALUATION

History
Any patient with anterior neck trauma is considered to
have an upper airway injury. The classic symptoms of
laryngeal trauma include hoarseness, laryngeal pain, dyspnea, and dysphagia (Table 77.1). It is surprising that no
single symptom seems to correlate well with the severity of
injury (2). When the laryngeal lumen is severely compromised, aphonia and apnea occur, signifying the need for
immediate establishment of an alternative airway.

Physical Examination
After trauma, a thorough physical examination of the neck
is needed to identify associated neurovascular injuries.
Cervical spinal injuries must be ruled out for all patients
with neck trauma. Active bleeding, expanding hematoma,. bruits, and the loss of pulses are signs of vascular

DIAGNOSIS
lD LARYNGEAL
TRAUMA
Symptoms
Hoarseness
Pain
Dyspnea
Dysphagia
Signs
Stridor
Hemoptysis
Subcutaneous emphysema
Laryngeal tenderness
Loss of thyroid cartilage prominence
Vocal fold immobility
Laryngeal hematoma
Laryngeal edema
Laryngeal lacerations
Radiology
Computed tomography
Arteriography
Cervical spine radiography
Contrast esophagography

injury. The usual signs of laryngeal trauma include stridor,

hemoptysis, subcutaneous emphysema, and tenderness or
deformity of the laryngeal skeleton. The presence of tenderness to palpation helps to differentiate an acute laryngeal fracture from an old deformity. The type of stridor
can suggest the location of the lesion. Inspiratory stridor
typically indicates partial supraglottic airway obstruction,
as might occur from edema, hematoma,. foreign body, soft
tissue injury, or cartilaginous fractures. Expiratory stridor
may portend a lower airway abnormality caused by a tracheal injury. Combined inspiratory and expiratory stridor
suggests partial obstruction at the level of the glottis.
Cervical subcutaneous emphysema is associated with
loss of the integrity of the upper aerodigestive tract and
is thought to occur through shear forces of the laryngeal
cartilage against the vertebral bodies (10). The amount of
air can range from slight soft tissue emphysema to massive
pneumomediastinum. Associated soft tissue derangements
of the larynx can produce a ball-valve effect that forces
massive amounts of air into the neck and chest as well.
Further compromise of the airway can be caused by tracheal displacement or tension pneumothorax. Care should
be taken to avoid excessive mask ventilation in patients
with laryngeal trauma as this can worsen subcutaneous
emphysema and potentially cause a pneumothorax (11).
Direct fiberoptic laryngoscopy is an integral component for evaluation of the patient with blunt laryngeal
trauma. The larynx is examined for mobility of the vocal
folds, position of the arytenoid cartilages, hematoma,.
lacerations, and airway patency. Rigid esophagoscopy is
the best way to examine the hypopharynx and esophagus

Chapter 77: Laryngeal Trauma

when indicated,. but should only be carried out after cervical spine injury has been excluded (12). In patients with
minor laryngeal injuries, strobovideolar:yngoscopy should
be performed to better assess subtle intricacies of vocal
fold function (13).

Radiologic Evaluation
Computed tomography (Cf) (Fig. 77.1Aand B) has clearly
become the most useful radiologic examination for evaluating laryngeal trauma ( 12,14-16). cr is most useful when
the results influence treatment. as opposed to documentation of an obvious injury when management will not
be changed. Two groups of patients may not benefit from

1143

cr examination: (a) Patients with minimal anterior neck

trauma and normal physical findings and (b) Patients
with obvious fractures, large endolary:ngeal lacerations, or
severe penetrating injuries. While the latter patients will
most often need tracheotomy, direct laryngoscopy, and
open exploration, many authors now agree that cr can be
of benefit even in this group in planning structural repair
( 15). The practical side of this is that most patients in this
category will have been intubated and had a cr of the
neck already performed by the time one is consulted. All
patients in the intermediate group should undergo cr to
assess the ex:tent of lru:yngeal injury. When used, cr helps
to confirm indirect or Bexible laryngoscopic findings, to
detect cartilage fractures that are not clinically apparent. to

D
Figure 77.1 A:. Minimally displaced laryngeal fracture. B: Moderately displaced laryngeal fracturQ.
C: Severely dlsplaa~d laryngeal fracture. D: Clsplaald cricoid fracture.

1144

Section V: Trauma

assess poorly visualized areas, such as the subglottic and

anterior commissure regions, and to identify associated
cervical injuries ( 14).
Special radiographic studies can be useful in identifying injuries associated with laryngeal trauma, especially
with penetrating trauma. Cervical or arch arteriography
continues to be most commonly used to identify vasrular
injury, although helical cr, MR angiography, and color
duplex: ultrasonography are replacing this in some institutions ( 12, 17). Pharyngeal and esophageal mucosal penetration can be identified with the use of a Gastrografin
followed by barium swallow examination, although this
should be pursued with caution due to the risk of aspiration associated with laryngeal injury. Radiographs of
the cervical spine are needed to rule out vertebral injury.
Partirular care is taken to visualize the entire cervical spine
to avoid missing injuries of the lower cervical vertebrae.
Ultrasonography has been considered as an adjunctive
diagnostic aid in acute laryngeal trauma due to its mobility
and easy handling; however, it is not widely utilized (18).

maintaining the airway and restoring function as judged by

lack of dependence on a tracheostomy and by voice quality.
These goals are universally accepted, but the most appropriate methods to achieve them are controversial (19).

Emergency Care
The initial evaluation and treatment of a trauma patient
consists of airway preservation, cardiac resuscitation, control of hemorrhage. stabilization of neural and spinal injuries, and a systematic investigation for injuries to other
organ systems (Table 77.2) . Controversy exists regarding
the best way to establish an alternative airway in the presence of laryngeal trauma (19). If orotracheal intubation
is performed in the setting of laryngeal trauma, it is best
done under direct visualization by experienced personnel
using a small endotracheal tube with a high-volume, lowpressure cuff with an otolaryngologist present ( 12). These
requirements cannot always be met when laryngeal trauma
is present. However, the attempted endotracheal intubation of a traumatized larynx can cause iatrogenic injury or
the loss of an already precarious airway. For these reasons,
some authors strongly recommend tracheotomy with local
anesthesia rather than endotracheal intubation for persons
who have sustained laryngeal trauma and need an alternative airway (2, 15,20). Patients with minimal laryngeal

MANAGEMENT
Figure 77.2 shows a management protocol for acute injuries to the larynx. There are two primary goals in the management of acute laryngeal trauma-preserving life by

Hilltllry Of NeCk Trauma

Suspicion tl Laryngeal Trauma

Examine for Physical Si!JIS of Injury

lmpenc:lingAirwayOIHIII'Uction+------------"----------+Airway Appears Stable

U nstabls airway

Hematoma, amal
laceration but
endalarynx intaot

___l___

Significant mucosal

Mid to

ec:lemi, hern&Uimll 4MC.,

dillplacec:llr-.re

abnotmal!y

modetale

Normal
endolatynx

l8olatad fraclln, clllf)laced or

but
lndOI&Iyrol il'ltlld

angu~ lhyrold C8J111age

Oillplaced 1hyroid
or cricoid cartilage
fracture

Open exploration Of neck with

open reduction and internal
fixation of fracture without

Ncrnllpie011hyr<*l
cartilags fracture with
stable aftlay

Normal

1hyrotomy
Further
work~oiHMirvati<m

Laryngeal cartilegl unlllillll, anlilrior

oommillure diiNptlc:l. m.-ve mUOOMI
injuries

ORIF fractu rea: repair mucosal

lacerations, consideration far
enc:lolaryngeal stent

Laryngeal aertillgl
and amenor oommillla'e
both repairatll8

E>cposec:l cartilage,
L.---endolaryngeal
disruptiOn

No exposed cartilage, no
internal disruption, minimal
laceration

ORIF fractures: repair

mucosal lacerations and
anterior r::ommiBSUre

Figure 77.2 Management algorithm for suspected laryngeal injury.

ObservatiOn

Chapter 77: Laryngeal Trauma

EMERGENCY CARE
LARYNGEAL TRAUMA
Multisystem trauma
Establish airway
Cardiac resuscitation
Control of hemorrhage
Stabilization of spinal injuries
Adult airway
Tracheotomy under local anesthesia or rigid bronchoscopic
intubation
Alternatively, endotracheal intubation only with:
Experienced personnel
Small-diameter endotracheal tube
Pediatric airway
Rigid bronchoscopic intubation followed by tracheotomy

lnJUiy, documented with flexible laryngoscopy and cr,

can safely undergo careful endotracheal intubation if it is
needed to manage other injuries. Such intubation should
be performed by a highly experienced physician to avoid
further injury to the larynx.
A child with a traumatized larynx presents a special
case because it usually is difficult to perform tracheotomy
under local anesthesia in this situation. Inhaled anesthesia with spontaneous respirations is used to achieve bronchoscopic intubation, which allows direct visualization of
laryngeal injuries and prevents additional iatrogenic injury
(11,21). Some authors recommend needle cricothyroidotomy and jet insufflation for patients younger than 12 years
(22). However, obtaining a needle cricothyroidotomy may
be difficult with loss of laryngeal landmarks, and jet insufflation may worsen subcutaneous emphysema or pneumomediastinum (22).

1145

TREATMENT
LARYNGEAL TRAUMA
Medical
Voice rest
Systemic steroids
Elevate head
Humidified air
Antibiotics
Antireflux measures
Surgical
Tracheotomy
Endoscopy
Exploration
Thyrotomy
Closure of lacerations
Insertion of stents for disrupted anterior commissure
Grafting for severe mucosal loss only
Fixation of fractures

free margin of the vocal fold, large mucosal lacerations,

exposed cartilage, multiple and displaced cartilage fractures, avulsed or dislocated arytenoid cartilages, and vocal
fold immobility (15,16,20).
Injuries likely to necessitate the additional use of endolaryngeal stenting include disruption of the anterior commissure, multiple and displaced cartilage fractures, and
multiple and severe endolaryngeal lacerations. In general,
stenting is avoided if possible, but may be indicated in the
management of these injuries to prevent loss of the normal
scaphoid shape of the anterior commissure, to stabilize
severely comminuted fractures or lacerations, and to prevent endolaryngeal stenosis. Penetrating trauma is more
likely to necessitate open exploration than is blunt trauma.

Treatment Decision Making

Medical Treatment

Management is divided into medical and surgical treatment according to the extent of injury as determined at
physical examination and Cf (Table 77.3). The decision
to treat a patient medically or surgically is determined by
the likelihood that the injury will resolve without surgical
intervention. The following conditions are likely to resolve
spontaneously without serious sequelae: edema. small
hematoma with intact mucosal coverage, small glottic or
supraglottic lacerations without exposed cartilage, and
single nondisplaced thyroid cartilage fractures in a stable
larynx (15,16,20). Some evidence, however, suggests that
the repair of even single nondisplaced angulated fractures
can prevent subtle vocal changes, as shown by acoustic
impedance (23). Strobovideolaryngoscopy may be useful
in determining which minor injuries may cause phonatory
disorders ( 13) Injuries likely to necessitate open laryngeal
exploration and repair include lacerations involving the

The goals of adjuvant therapy are to eliminate further

injury and to promote rapid healing. The clinical course
after blunt trauma to the neck is uncertain; therefore,
hospitalization in a monitored environment for at least
24 hours is recommended to observe for signs of progressive airway compromise and worsening oflaryngeal edema
(24,25). Preparations are made for possible emergency tracheotomy.
Bed rest with elevation of the head of the bed for several
days helps resolve laryngeal edema. A period of voice rest
can minimize further edema or reduce the progression of a
hematoma or subcutaneous emphysema. The use of cool,
humidified room air helps prevent crust formation in the
presence of mucosal damage and transient ciliary paralysis.
Additional oxygen is usually not needed unless there is evidence for oxygen desaturation, the advent of which should
prompt further investigation.

1146

Section V: Trauma

Nebulized racemic epinephrine and systemic corticosteroids have been used sporadically in the management of
laryngeal trauma in an effort to reduce edema and subsequent fibrosis, but no convincing clinical or experimental
evidence supports use of this therapy. If used, they are most
likely to be of benefit in the first few hours after injury. If
there is evidence of a mucosal tear or laceration, antibiotics
with coverage toward mixed upper aerodigestive track flora
can be useful as prophylaxis against infection, although
this has not been proven clinically (25).
A patient with a laryngeal injury is restricted at first to a
clear liquid diet with intravenous supplementation as necessitated by other injuries. Nasogastric feedings usually are
unnecessary, and passage of a nasogastric tube can worsen
the injury. Prolonged use of a nasogastric tube can traumatize the posterior larynx and promote gastric acid reflux. The
use of H2-blocking agents and proton pump inhibitors can
help prevent the development of reflux laryngitis, which
may be important in preventing scar formation and stenosis
in the presence of laryngeal mucosal injury (12,25). Patients
with hypopharyngeal tears are given nothing by mouth
initially, and if associated with severe laryngeal injury,
may benefit from gastrostomy tube placement early on as
opposed to placement of a nasogastric feeding tube.

Surgical Treatment
The optimal timing of endoscopic evaluation and surgical management of laryngeal trauma is controversial
(2,15,16,20). Some reports indicate that waiting several
days after trauma allows the edema to resolve so that
endolaryngeal lacerations can be better identified and
approximated (11 ). Currently, most authors agree that
early exploration offers the opportunity for complete
assessment of the injury and may result in a lower postoperative infection rate. quicker healing. less granulation
tissue. and less scarring. Results of several large laryngeal
trauma case series suggest that early surgical intervention
is associated with better outcomes and is more effective
in allowing accurate identification of mucous membrane.
muscle. and cartilage injuries, which can then be repaired
primarily (15,20,26). In practicality, some delays in treatment may be unavoidable due to associated injuries such
as an unstable cervical spine or traumatic brain injury.
Endoscopy is used to ascertain the extent of injury to the
larynx and adjacent aerodigestive tract when further surgical management is being considered. A thorough direct
laryngoscopic examination is performed in which the entire
larynx and hypopharynx are visualized. If dislocated arytenoid cartilage is found, endoscopic reduction should be performed with efforts focused on restoring proper height of
the vocal process (27). Bronchoscopy also is used to evaluate
the subglottis and trachea. Esophagoscopy is performed to
rule out unsuspected esophageal perforation. When injuries
that clearly necessitate surgical management are identified
at endoscopy, open exploration is performed immediately.

The extent of injury found at endoscopy or open exploration determines the extent of surgical therapy. It may be as
limited as tracheotomy to establish an airway or as extensive as open reduction and internal fixation with stenting.
Endoscopic or CT evidence of laceration of the mucous
membrane. exposed cartilage. immobility of the vocal folds,
or displaced or comminuted fractures of cartilage are indications for open exploration. Open reduction and fixation of
cartilage fractures is definitely preferable to closed reduction
over a bronchoscope and subsequent placement of a stent
because of the difficulty of obtaining an adequate reduction
in a closed manner and because the dynamic nature of the
stresses on the larynx necessitate continued fixation to provide stability. In the management of severe injuries, such as
large mucosal lacerations involving the anterior commissure. comminuted cartilage fractures, and avulsion of the
arytenoid cartilage. open exploration through a laryngofissure or thyrotomy with stenting is indicated (15,20).
Exploration is performed through a horizontal skin
incision in a skin crease at the level of the cricothyroid
membrane. Subplatysmal flaps are elevated superiorly to
the level of the hyoid bone and inferiorly to just below the
cricoid cartilage. The incision can be extended to explore
and repair associated neural, vascular, or visceral injuries.
The infrahyoid strap muscles are separated in the midline
and retracted laterally to expose the laryngeal skeleton and
fractures. The thyroid cartilage is incised at the midline.
or a preexisting vertical fracture in close proximity to the
midline can alternatively be used, and the endolarynx is
entered through the cricothyroid membrane. Under direct
vision, the incision is extended superiorly through the
anterior commissure to the thyroid membrane. The entire
endolarynx is examined to identify the extent of the injury
(Figs. 77.3 and 77.4). The arytenoid cartilages are palpated
to assess their position and mobility.
All mucous membrane. muscle. and cartilage with a viable blood supply are preserved and restored to their original position. Because it is the primary factor responsible for
formation of granulation tissue and fibrosis, exposed cartilage must be covered primarily. Failure to do so necessitates
grafting and healing by secondary intention. Lacerations
are meticulously approximated with 5-0 or 6-0 absorbable
suture material (Fig. 77 .5). Mucosal advancement flaps
may be needed to relieve tension on suture lines and to
achieve complete cartilage coverage.
Cartilaginous fractures may be repaired with wire. nonabsorbable suture. resorbable miniplates, or permanent
miniplates. Miniplates offer increased opportunity for
reconstitution of the skeletal anatomy of the thyroid or cricoid cartilage as compared to less rigid means of fixation
(28,29), and have become the mainstay of many authors'
armamentarium (30-33). Resorbable plates generally
resorb within 1 to 2 years and are particularly attractive due
to their relative ease of adaptability (34). However, screws
of both resorbable and nonresorbable type tend to pull out
easily in cartilage. and an untapped, undersized drill bit

Chapter 77: Laryngeal Trauma

1147

jl

t.!

Lacerated true
vocal fold

Fractured
thyroid cartilage

Figure 77.4 Ulceration of true vocal fold and hematoma of false

vocal fold.

Figure 77.3 Fracture of thyroid cartilage.

formation than with primary closure. In the rare situation

in which a graft is needed, mucous membrane, dermis, and
split-thickness skin are suitable Mucous membrane most
closely resembles the normal endolaryngeal epithelium,
but use of this tissue carries high donor-site morbidity
and necessitates entering the oral cavity. Grafting never is a
substitute for careful closure of laryngeal lacerations.

should be used along with careful insertion technique in

order to avoid shear failure (31,33,34).1f a screw does strip,
nonresorbable or long-lasting reso:rbable suture can still be
used to secure the cartilage to the plate, while still gaining increased rigidity &om the plate itself. Small fragments
of cartilage with no intact perichondrium are removed to
prevent chondritis. 1he anterior margin of each true vocal
fold is sutured to the thyroid cartilage or its external perichondrium at the thyrotomy site to reconstitute the anterior commissure (Fig. 77.5). If the anterior commissure is
devoid of epithelium, a preformed ked or reinforced polymeric silicone sheeting can be placed to prevent web formation. lhe thyrotomy is dosed with wire. nonabso:rbable
suture, or miniplates (Fig. 77.6). If part of the anterior aicoid ring is lost. suturing the infrahyoid strap muscles into
the defect can help maintain the airway and voice

Grafting
Adhering to the principles of conservation of normal
anatomic relations and immediate surgical management
makes the need for a graft rare. Mucous membrane or skin
grafts have been used to cover areas of exposed cartilage
that cannot be dosed primarily; however, these wounds
must heal by second intention, which causes greater scar

Figure 77.S Repair of lacerations.

1148

Section V: Trauma

FiguN 77.6 Resorbable plate fixation of laryngeal fracture.

1, thyroid cartilage; 2, biomaterial; 3, gap; 4, swollen vocal cords;
5, esophagus; 6, carotid sheath; 7, anterior strap muscles; B, screws
placad in biomaterial and 1hyroid cartilage.

Stents
Laryngeal stents can be used initially for internal fixation

devices and thereafter prevent endolary:ngeal scarring and

maintain the internal configuration of the larynx. Although
the presence of a stent can increase the risk of infection and
formation of granulation tissue. the clinical :findings sometimes dictate stenting (35). Multiple cartilaginous fractures

that cannot be stabilized adequately with open reduction

and internal fixation and atensive lacerations involving
the anterior commissure are specific indications for the use
of stents. In the presence of a stable laryngeal skeleton with
an intact anterior commissure before thyrotomy, stenting
is not needed. Massive mucosal injuries may necessitate
stenting to prevent mucosal adhesions (Fig. 77.7). Stents
alone. however, are not a substitute for primary closure
of mucosal lacerations and careful reduction and internal
:fixation of fractures (15,20).
1he stent must be :fixed in the larynx in such a way that
it moves with the larynx during swallowing and am be
consistently and easily recovered by means of endoscopy
alone. A useful method is to pass a heavy, nonabsorbable
suture through the stent and the larynx at the level of the
laryngeal ventricle and another at the cricothyroid membrane. lhese are tied over buttons outside the skin. There
is some controversy about how long to leave a stent in
place. The desired laryngeal stabilization must be achieved
and scar formation prevented, but the risk of infection
and wound necrosis associated with prolonged stenting must be considered (36). If an analogy can be drawn
with pedianic single-stage laryngotracheal reconstruction
with endotracheal tube stenting, stenting for longer than
1 week does not confer any advantage {37). The stent is
removed by means of direct laryngoscopy, and the operative result is assessed. Granulation tissue can be removed
with conservative use of a carbon dioxide laser or laryngeal
microdebrlder. An association has been suggested between

-----e
Orientation
of stent
with mattress
sutures

True cord ---P----4'~

lacerations
sutured

--------6

Figure 77.7 Fixation of endolaryngeal st&nt using nonabsorbable sutures.

Chapter 77: Laryngeal Trauma

the development of granulation tissue and stent colonization with Staphylococcus aureus and Pseudomonas aeruginosa,
and it is recommended that prophylactic antibiotics be
used (38). The need for additional endoscopic manipulation is determined with serial flexible laryngeal examinations. Decannulation is best deferred until the patient can
tolerate a reasonable period of plugging of the tracheotomy
tube.

Cricotracheal Separation
Cricotracheal separation is one of the more severe injuries associated with anterior cervical trauma and commonly occurs from clothesline injuries (39). Several factors
unique to this injury must be considered including a precarious airway. loss of cricoid support, injury to the recurrent laryngeal nerves, and late development of subglottic
stenosis. While cricotracheal transection often is associated
with asphyxiation at the time of trauma. respiratory distress may not be present if prefasdal tissues remain intact
Therefore, a high index of suspicion is required for diagnosis of this type of injury. The airway is best controlled
by means of tracheotomy with the patient under local
anesthesia. When this is impossible, tracheotomy is performed after careful passage of a ventilating bronchoscope.
Intubation of the patient with laryngotracheal separation can result in loss of airway due to placement of the
endotracheal tube through the mucosal laceration into the
soft tissue of the neck, with disastrous consequence. If the
patient has successfully been intubated before evaluation,
the diagnosis may not be established until extubation. cr
may aid in diagnosis of the intubated patient showing balloon overinflation or herniation (40).
If the cricoid cartilage is intact, the mucous membrane
is repaired directly with absorbable suture. To distribute
the tension on the wound away from the cricotracheal
anastomosis, nonabsorbable sutures are placed from the
superior aspect of the cricoid cartilage to the inferior aspect
of the second tracheal ring. If the cricoid is fractured, the
effectiveness of repair is limited by the stability of the cricoid cartilage after internal fixation. Reconstitution of the
severely injured cricoid cartilage,. with the assistance of
internal fixation and stenting, is preferable to extensive
resection of the cricoid and thyrotracheal anastomosis.

Severed Recurrent Laryngeal Nerve

Management of a severed recurrent laryngeal nerve continues to be controversial. Even with careful microscopic
repair of the transected nerve, vocal fold mobility is not
regained owing to the mixture of abductor and adductor
fibers in the nerve (41). Additionally. vocal fold synkinesis may develop after neurorrhaphy. Nerve regeneration
can prevent muscle atrophy. help maintain some strength
of voice,. and decrease rate of aspiration (41 ). Therefore,.
it appears that the best acute-phase management is

1149

immediate reapproximation of the nerve under an operating microscope.

COMPLICATIONS
Early recognition of laryngeal injuries and the application of consistent management principles have decreased
the morbidity and mortality from laryngeal trauma
(Table 77.4). Success is measured in terms ofrestoration
of the voice, airway. and deglutition. Bent has proposed a
modification of Shaefer's original grading system that may
be useful in predicting successful outcomes (Table 77.5)
(5,20). Among patients with edema, hematoma. or minor
lacerations, excellent recovery of both voice and airway
usually can be achieved without surgery or with minimal
surgical intervention, such as tracheotomy or endoscopy.
With severe lacerations and cartilaginous fractures, good
results can be achieved with early primary repair of lacerations and internal fixation of fractures. In the two largest
published series of laryngeal trauma. greater than 97% of
patients were able to be decannulated using these treatment protocols (16,20). In these same series, voice quality
was graded as poor in only 1 patient out of the combined
total of 251 patients (16,20). If present, suboptimal voice
outcome may be related to impaired lengthening of the
vocal folds secondary to scarring or superior laryngeal
nerve injury (42).
The most common problem in the immediately postoperative period is development of granulation tissue, which
most often happens in the presence of bare cartilage. This
problem often is the precursor to fibrosis and stenosis.
Many techniques have been used in attempts to arrest formation of granulation tissue,. including the use of systemic
and intralesional corticosteroids, long-term splinting, and

, . . COMPUCATIONS

..... LARYNGEAL TRAUMA

Granulation tissue
Prevent by covering all exposed cartilage
Avoid stents when possible
Careful excision
Laryngeal stenosis
Excision with mucosal coverage
Stenting selected cases
Laryngotra cheopl asty
Tracheal resection with reanastomosis
Vocal fold immobility
Observe
Vocal fold injection
Thyroplasty-type vocal fold medialization
Arytenoidectomy and vocal fold lateralization for bilateral
paralysis
Manifested as failure to decannulate and inadequate voice.

1150

Section V: Trauma

INJURY GROUPS
Group 1: Minor endolaryngeal hematoma/lacerations without
detectable fracture
Group 2: Edema, hematoma, minor mucosal disruption without
exposed cartilage; nondisplaced fractures on CT scan
Group 3: Massive edema, mucosal tears, exposed cartilage,
vocal cord immobility, displaced fractures
Group 4: Group 3 plus three or more fractures and massive
mucosal damage requiring stenting
Group 5: Laryngotracheal separation

low-dose irradiation, but these methods have had little success. Probably, the most effective technique is to minimize
the initial formation of granulation tissue by attempting to
cover all exposed cartilage meticulously in primary closure
of laryngeal lacerations. Control of reflux through the postoperative use of H2 blockers and proton-pump inhibitors
may be beneficial in decreasing the formation of granulation tissue (12). Using intraluminal stents only in highly
selected cases, as described earlier, and keeping the stents in
place for the minimum amount of time needed decreases
the amount of granulation tissue that forms.
Despite strict adherence to proper principles of management of laryngeal trauma, fibrosis and stenosis can occur.
Therapeutic measures depend to some extent on the level
of stenosis. Supraglottic stenosis often can be corrected
with simple excision of the scar tissue and local advancement flaps for wound coverage. Stenosis repair may be
performed through an open or endoscopic approach (3).
Extensive areas of stenosis may necessitate the removal of
a large portion of the epiglottis or aryepiglottic fold. In
rare instances, supraglottic laryngectomy may be necessary if depending on the degree of stenosis or cartilaginous
injury (43). A keel or stent can be used as needed to maintain the repair.
Rehabilitation from glottic stenosis depends on the
extent of the lesion. Thin anterior glottic webs can often
be lysed and repaired using a microflap technique (see
Chapter 68) (44). Posterior glottic webs or interarytenoid
scarring may require arytenoidectomy or related procedures (see Chapter 69). Extensive glottic stenosis often
necessitates a laryngofissure with direct excision of the
stenotic area followed by placement of a rib cartilage graft
with or without a stent.
Subglottic stenosis continues to be difficult to manage, no matter what the cause. Less extensive lesions can
be managed with repeated dilation or conservative noncircumferential laser excision of the scar tissue. Balloon
dilation has been shown to be safe and effective while
maximizing the "radial direction of dilation" compared to
standard bogie dilation (45). More serious stenosis may
necessitate anterior or posterior cricoid splits with cartilage

grafting to increase the size of the subglottic lumen.

Stenting usually is needed as are numerous endoscopic
procedures to excise granulation tissue after removal of the
stent. Mitomycin C has shown promise as a topical agent
to help prevent recurrent scar formation (3,46). While the
exact mechanism of action of Mitomycin C is unknown,
it is believed to decrease scar formation through inhibition of fibroblast migration (3). Marked tracheal stenosis
in a short segment is managed by means of resecting the
stenotic area and performing end-to-end tracheal anastomosis (4 7). Lesions up to 4 em in length can be resected
with laryngeal release techniques; however, the results with
many of these techniques are disappointing, and prevention of these complications continues to be the optimal
treatment (see Chapter 62).
After blunt trauma.. persistent immobility of the vocal
fold may be caused by recurrent laryngeal nerve injury or by
cricoarytenoid joint fixation or dislocation. Differentiating
these causes is essential in selecting the proper form of
therapy, and is best accomplished by observing vocal fold
motion with fiberoptic laryngoscopy and videostrobolaryngoscopy followed by direct palpation of the arytenoid
to assess its mobility (27). Laryngeal electromyography
(EMG) may be necessary to distinguish vocal fold paralysis from arytenoid dislocation (27,48). If the arytenoid
cartilage is mobile, the vocal fold is observed for as long as
1 year to await the possible spontaneous return of recurrent laryngeal nerve function; however, laryngeal EMG can
shorten the waiting period by providing key prognostic
information regarding spontaneous recovery possibilities (see Chapter 69). If aspiration or dysphonia is severe,
injecting the vocal fold with an augmenting material such
as gelfoam, fat, hydroxyapatite paste, hyaluronic acid, or
one of many available materials can be a temporizing
measure ( 49-52). Persistent paralysis resulting in an inadequate voice can often be rehabilitated with appropriate
laryngeal framework surgery (53,54). In the case of unilateral fixation of the arytenoid cartilage with adequate voice
and airway, no treatment is needed. Bilateral arytenoid fixation or recurrent laryngeal paralysis with a compromised
airway often is managed with arytenoidectomy and vocal
fold lateralization (see Chapter 69).

CONCLUSION
Although each instance of laryngeal trauma presents a
unique therapeutic challenge. using basic primary treatment principles greatly simplifies the management plan.
When clinically possible, flexible laryngoscopy provides
essential information on the nature and severity of injury,
which subsequently directly factors into treatment decisions. The use of cr scans in some cases oflaryngeal trauma
may obviate the need for open exploration and often is
helpful in diagnosis and treatment planning. Tracheotomy
rather than endotracheal intubation often is the most controlled method for establishing an airway when necessary.

Chapter 77: Laryngeal Trauma

Immediate open exploration for serious injuries allows primary closure of all mucosal lacerations and prevents some
long-term complications of laryngeal trauma. Stenting is
not needed when the cartilaginous skeleton is stable after
internal fixation and when mucosal coverage of the anterior commissure can be reconstituted. Use of an early primary management protocol to manage laryngeal trauma
should predictably maintain laryngeal function.

A high index of suspicion is the most valuable aid to

early diagnosis.
cr is the most useful radiologic examination in the
evaluation oflaryngeal injury.
Management is determined by the findings at flexible laryngoscopy and cr.
Hematoma. small lacerations, and edema are likely
to resolve with medical therapy alone.
Cartilage fractures, large lacerations with exposed
cartilage, disruption of the anterior commissure,
and arytenoid injuries necessitate surgical repair.
Tracheotomy is the most controlled method for
establishing an airway with an injured larynx.
Mucosal repair is best accomplished immediately.
Primary mucosal coverage of exposed cartilage most
effectively prevents development of granulation tissue.
Grafts are used for coverage of exposed cartilage
only when primary mucosal coverage is impossible.
Stents are used only in the presence of anterior commissure injuries or cartilage fractures that are unable
to be adequately stabilized.

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1152

Section V: Trauma

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used as augmentation substance for treatment of glottal insufficiency: safety aspects and vocal fold function. Laryngoscope
2002;112:2211 .
52. Courey MS. Injection laryngoplasty. Otolaryngol Clin North Am
2004;37:121.
53. Isshiki N. Progress in laryngeal framework surgery. &ta
Otolaryngol2000; 120: 120.
54. Selber J, Sataloff R, Spiegel J, et al. Gore-Tex medialization
thyroplasty: objective and subjective evaluation. J Voice 2003;
17:88.

Robert .M. Kellman

In this age of rapid transportation and increasing urban

violence, severe facial trauma is an entity that the otolaryngologist-head and neck surgeon is likely to encounter.
Complex. facial trauma may refer to blunt and/or penetrating trauma resulting in multiple facial fractures and varying degrees of soft tissue injury or loss.
Skeletal facial trauma is frequently subdivided into
fractures of the frontal sinus, nasoethmoid complex,
zygomaticomaxillary complex,. midface, dentoalveolar
structures, mandible,. and other unusual fracture patterns. Complex facial trauma can then refer to either the
multiplicity of areas involved (i.e., panfadal fractures) or
the degree of severity of involvement of a given area. For
purposes of this chapter, massive facial trauma refers to
high-energy blunt or penetrating trauma leading to severe
bony displacement, comminution or frank bone loss, and/
or involvement of multiple anatomic areas and reducing
the availability of anatomic reference points for fracture
reduction. These injuries may be associated with severe
soft tissue lacerations, avulsions, or globe or central nervous system injuries. Regardless of the precise definition of
massive facial trauma, it is our contention that these injuries can be managed successfully by adherence to the same
basic principles that lead to successful outcomes from less
complex trauma.

BONE HEALING
Bone is a complex tissue made up of a collagen matrix
mineralized with calcium phosphate (hydroxyapatite)
crystals. Interspersed within bone are cellular components
that mediate bone resorption, deposition, and metabolism. Thicker areas of bone typically involve two structural
components: an outer cortical or dense bone layer and an
inner cancellous or spongy bone layer. Thinner sections of
bone are lamellar and lack significant cancellous bone or
marrow space. Nutrition is supplied to bone through the

Sherard A. Tatum

outer layer of periosteum and inner open circulation of the

marrow space ( 1).
Fracture results in disruption of the bone matrix, surrounding soft tissue and, if applicable,. marrow space. This
disruption allows blood and inflammatory cells to flood
the area. A hematoma forms, which matures through
granulation tissue, fibrous tissue,. cartilage, and then bone
or directly from fibrous tissue to bone depending on the
embryologic origin. This callous formation allows indirect healing to occur when the edges of the bone are not
approximated. Mineralization eventually occurs if motion
is not excessive. If not anatomically reduced, segments heal
in a new position, which may lead to deformity and dysfunction (2).
If the distance between bone fragments is decreased
by anatomic reduction of the fracture,. then healing will
occur with less callous formation and diminished alteration of anatomy. Areas of the fracture that are abutted and
compressed will heal by contact healing or direct osseous
formation without significant callous formation. Direct
osseous healing is not likely to occur along the full length
of a fracture even if it is well reduced. Microgaps heal by callous formation or gap healing in which bone is laid down
directly perpendicular to its normal orientation followed
by remodeling to change this orientation. Regardless, the
fragments heal in anatomic position (3).
Problems with the bone-healing mechanism can lead
to clinical complications of fractures. Delayed union refers
to reduced or absent mineralization of a fracture line 8 to
12 weeks after immobilization. Malunion occurs when a
fracture heals by osseous union with segments in nonanatomic position. Fibrous union occurs when progression of
indirect healing to ossification does not occur. A nonunion
can refer to fibrous union, although it typically connotes a
wider gap with very poor function, whereas fibrous unions
may not result in a functional deficit. Pseudoarthrosis
refers to a fibrous union that is mobile enough to function

1153

1154

Section V: Trauma

like a joint. This phenomenon might be a desirable result

for a subcondylar fracture that has resulted in temporomandibular joint ankylosis. Otherwise the mobility leads
to dyBfunction and pain. Inadequate stabilization and
infection are major causes of these healing problems (4 ).

FRACTURE PATHOPHYSIOLOGY
AND CLASSIFICATION
Fractures ocrur when forces are applied that exceed the
stress capabilities of bone, leading to a disruption of
the mineralized matrix with additional disruption of the
associated soft tissue. Fracwres may be simple, involving
a single disruption between two bone segments, or comminuted, meaning multiple bony fragments exist in the
separation between bone segments. Displacement refurs
to the alteration in anatomic relationships of bony segments. This alteration can ocrur as a result of the energy
of the blow itself or because of Wlopposed muscle pull.
.Angulation is the change in angle of the long axis of the
bone across the fracture. Distraction refers to the distance
between bone segments across a fracture, and rotation is
the orientation alteration of bone segments along their
long axis. A fracwre is considered favorable if it is oriented
such that muscle pull vectoiS act to compress the fracture.
An unfavorable fracture is one oriented such that muscle
pull vectors act to displace the fragments (Fig. 78.1).
The concept ofopen or compound fractures relates to the
exposure of fractured bone outside the soft tissue, leading to
bacterial contamination. This idea is a little confusing in the
face because of the oral nasal, and sinus cavities. Certainly,
fract.u.res involving gross lacerations of facial skin or oral
mucosa aposing bone are open fmctures. Typically, fractures involving tooth-bearing bone even without mucosal
laceration are considered open because of exposure to the
orai flora through the periodontal tissue Fractures through
the nasal cavity involving mucosal lac:aations are likewise

exposed to nasal flora. Fractures through an uninfected sinus

cavity may not initially involve bacterial contamination;
howeva; a blood-filled sinus is likely to become colonized
fairly quicldy: Therefore, few facial fractures would not be
considered open. Isolated mandibular ramus or subcondylar fractures and zygomatic arch fractures are among these.
The amOWlt of energy associated with the injw:y tends to
aHect the charac:teristics of the injwy. Low-energy impacts
such as fist blows tend to lead to less comminuted and leas
displaced fractures. High-ene~gy impacts are more typically associated with comminution. greater displacement.
and a greater degree of soft tissue injury. The rate of energy
dissipation into the tissue is the true determinant. A hard
object striking the face is more likely to lead to comminution than a fist striking with the same ene~gy because the
energy of the blow is transferred to the tissue more quickly.
The kinetic energy of the object may be greater as well
Penetrating trauma is similru;. with low-energy missiles creating less injwy than high-enetgy missiles. However, missile design comes into consideration. A high-energy missile
with a hard surface may exit the body fairly quickly, not dissipating all its energy into the body. A lower-energy missile
designed to apand, spiral, or tumble and dissipate most
of its energy before exit can be more damaging. However,
the amount of shock wave energy from the missile impact
determines the degree of collateral tissue damage. Pointblank gunshot woWlds have the added soft tissue injw:y of
the expanding propellant gases. 1hi.s blast injw:y can lead to
poor healing, infection. and fibrosis. Ballistia information
is helpful, but wound evaluation is still the best guide {5).

RATIONALE FOR RIGID FIXATION

Regardless of the etiology or classification of the fracwre,
the healing mechanism can be assisted with reapproximation of the fragments followed by fixation to create stability
and reduce movement of the bone fragments. Decreasing

Figure 78.1 A; Posterior body fracture with unfavorable angulation. Pull

of masseter musde distracts fracture. B: Favorable posterior body fracture.
Pull of wmporalls muscle compi'Qsses fracture. C: Unfavorable fract'Ure. Pull
of hyomandlbular musculatui'Q dimacts fracture. D: Favorable fracture orlen
tatlon. Pterygoid musculat:ui'Q compresses fracture. E: Unfavorable fracture
orientation. Pterygoid musculatui'Q distracts fracture.

Chapter 78: Principles in Rigid Fixation of tite Facial Skeleton

1155

movement ofthe bone fragments enhances ossification and

the progression to a bony union. Reestablishment ofblood

supply to deva.scularized bone fragments or bone grafts is
also enhanced by immobility. This lack of movement or
stability requires overcoming the biomechanical forces acting on the bone fragments. VaJ:ying degrees of stability are
imparted by different :fixation techniques. Rigid fixation of
fractures with plates and screws is thought to provide superior stability by overcoming functional forces applied by
the musculoskeletal system across a fracture {6). this concept is not universally accepted, however. Enhancements
in imaging capabilities and swgical exposure techniques
and a greater interest in maxillofacial trauma have paralleled the development of plating technology. 1hese developments may accoWlt for improved trauma outcomes.
Additionally, plates have been criticized for being palpable,
occasionally being visible, causing temperawre sensitivity,
inhibiting growth, and weakening bone by stress shielding.
Some of these criticisms are more theoretic than others,
but abso:rbable plating systems promise to alleviate most
of these problems. To obtain comparable strength, characteristics of abso:rbable plating systems currently require
huger plates and screws than their metal coWlterparts, so
they are not suitable for every indication. Howevet newer
reinforced materials may alleviate this problem {7,8).

BASIC PRINCIPLES OF RIGID FIXATION

1he central concept of rigid fixation is to return skeletal
fragments to their anatomic position and rigidly fixate
them in that position with an implantable device that provides sufficient strength across the fracture to maintain the
reduction against musculoskeletal fooces. F'mation plates
are designed to span a fracture and provide stress shielding and fracture stability. the plates are fixed to the bone
with screws. Each screw placed in the bone is a fixation
point. Larger plates made of stiffer material provide greater
sttess shielding and stability. Large screws provide stronger
fixation than small screws. Bicortical screws provide greater
stability than monocortical screws, and increasing the number of screws or fixation points anchoring a plate to a bone
segment increases stability. Compression or loading of the
bone across the fracture enhances stability by increasing
the friction between the fracture edges (9). Additionally, plate
location relative to bone thickness and the many complex
forces acting on the bone are important Generally speaking,
greater bone thickness is found when the forca acting on
the bone are greater; howeve:t more bone thickness allows
for longer screws, providing increased stability. Forces acting
to angulate a fracture distract one end ofa fracture and compress the other. A plate placed closer to the end being distracted is more likely to overcome those forces than a plate
located at the end being compressed because of mechanical
advantage related to the lem:principle {Fig. 78.2).
the previous statements are true within certain limitations. the more rigid a plate is, the more precise the bending
of the plate has to be to conform to the surface contours of

Figure 78.2 Muscle pull distracts superior border of fracture and

compresses inferior border of &ac:ture. Plate placement in (A.) prevents superior distraction. Plate placement in (B) does not.

the bone where it is to be applied. Otherwise, as the screws

are tightened, the bone may be pulled toward the plate.
creating disttaction (Fig. 78.3). To Oftl'COme this problem,
locking-screw plates have been developed. 1hese allow the
threaded screw head to lock into a corresponding threaded
plate hole, so the screw head locks to plate. This obviates the
need for the preciseness of the bend because the bone will
not be pulled to the plate. In mandibular rep~ monocortical miniplates have been found to be adequate to replace a
heavy bicortial plate so long as they are properly positioned
to overcome the disttacting forces that occur during function (10). Additional fixation points (i.e., screws) provide
additional stability; h~ the incremental increase in
stability decreases as the number of:fixation points increases
(11). 1he increase in stability must be weighed against the
additional exposure required and higher bulk of the larger
implant. lncreuing screw diameter must be 'Weighed against
the weakening of the residual bony buttress created by
increasing the screw hole size Increasing screw length into
cancellous bone adds little additional strength unless a second cortex. is engaged. Screw length beyond the applicable
bone thickness certainly adds no strength, and damage to
Wlderlying structures such as tooth roots could ocOJJ.

FIXATION DEVICE CLASSIFICATION

AND TERMINOLOGY
lhe terminology applied to plating systems is confusing
and nonuniform, because it is applied differendy by different manufaell.li'enl. Plating systems are usually identified

1156

Section V: Trauma

Figure 78.3 A: Plate is bent to appropriate contour

with bony cortex so that when screws are tightened,
lingual and buccal cortices are approximated. B: Plate Is
undarbent, approximating bucx:al cortex but distracting
lingual cortex. C: Plate Is overbent, approximating lingual
cortex but distracting buccal cortex.

either by their dimensions or by their application. 1he

term miniplate typically refenl to plates designed for screws
in the 1.2- to 2.5-mm range. The term microplate refen to
plates designed for screw diameters around 1 mm. There
are several intermediate sizes and now modular systems
with multiple plate and screw dimenaioll8. Larger systems
are designed specifi.cal1y for the mandible with screw diameters up to 2.4 mm or more and greater lengths for bicortical applications, including lengths up to 40 mm for lag
screw applications. Usually, as screw size increases, so does
plate thickness. So-called three-dimensional (3-D) plates
are available in mini and micro sizes. These plates have
added strength due to a lattice design ( 12).
Plating systems are sometimes designated according
to their proposed function, such as maxillary or zygomatic miniplates or mandibular miniplates. Although
screw dimensions may be the same,. mandibular miniplates are thicker than maxillary and zygomatic miniplates. Mandibular miniplates are typically 1 mm thick.
Mandibular systems are fwther delineated as trauma sets
or reconstruction sets, with the reconstruction sets offering
the thickest (3 mm or more) stiffest plates in the greatest
lengths and with the largest screws. Condylar prostheses
may be included. Specialty plates also exist that are prebent
for orthognathic surgery or with special configurations
useful for microvascular recoll8truction of the mandible.
Various mesh designs are used to replace defect areas in
non-load-bearing areas such as the orbital floor. Newer
o:rbital floor plares have been designed from human models to mimic the anatomical contoUIS (convexities and
concavities) of the o:rbital floor and medial wall providing
for more precise repairs.
Dynamic compression plates are designed to push fracture fragments together as the screws are driven. The plate

holes are ovoid, and the edges of the hole are slanted. 1he
holes for the screws are drilled eccentrically within the
plate holes so that when the screw is tightened, the head
slides down the slant. bringing the bone with it The plate
hole orientation determines the direction of movement
and compression. Standard dynamic compression plates
compress parallel to the plate across the fracture. Eccentric
dynamic compression plates have holes on the end that
are oriented to provide angular compression for the superior border of the mandible. Today, compression plates are
used less frequently than in the past. and eccentric dynamic
compression plates are rarely used.
Absorbable plates and screws can be used as well,
though to obtain strengths similar to titanium, larger
implants are required (13).

PRINCIPLES OF SCREW APPLICATION

For a screw placed in bone to serve as a stable fixation
point. the threads of the screw must engage or grip the
bone around the drill hole. Pa.ctors leading to inherent
bone weakness such as osteoporosis or osteitis are beyond
the surgeon's control. Adherence to good SUJgic.al technique,
however; will enhance the stability of the screw in the bone.
1he drill hole must match the inner screw shaft diameter. If
the hole is too small, excessive friction and stress will result
This excess can lead to shearing of the screw head or local
bone ischemia and resorption. The screw is held by a functional sleeve of bone around the drill hole that is the thickness of the screw threads (Fig. 78.4). 'Ibis thickness varies
from screw to screw but is typically on the order of 0.1 to
1.0 mm. Any imprecision in drilling can lead to reduction
of this sleeve of bone and a lar:ger than desired drlll hole.
High-speed drill chatter, bent drill bits, drlll angulation

Chapter 78: Principles in Rigid Fixation of tite Facial Skeleton

1157

position until the other screws are placed. Then it should

be removed and when possible replaced with a laJger
screw: An advance in screw design eliminates the need for
drilling. The tip of the screw is like a drill bit and the screw
is driven directly into the bone. Self-drilling screws allow
placement of the screws directly into the bone, avoiding
drilling altogether. These are especially helpful in thin
bone.

LAG SCREW APPLICATION

Figure 78.4 Detail of fixation screw In bone. The diameter of the

hole in the bone matches the inner core diameter of the screw, not
the outer thread dlamet:er of the screw.

change (ie., hand movement), or continued drilling once

the hole is complete can lead to attrition of the bone around
the drill hole. Excessive heat leads to delayed attrition from
osteocyte death. Therefore, ideal drilling is achieved with
a sharp straight drill bit. a low-speed drill, a drill guide, a
steady hand, and copious irrigation. 1he diameter of the
drill bit should match the diameter of the screw shaft without threads, not the diameter with threads. If a drill bit's
diameter matches the screw's outer diameter with threads,
then the screw can be pushed or pulled through the drill
hole without turning the screw. This situation is termed
gliding and is desirable only in lag screwing.
Tapping refers to the cutting of screw threads in the
drill hole. Most systems now have self-tapping screws that
have flutes beginning at the tip of the screw and extending several threads up the screw to allow for the cutting
of the bone into a thread pattern. Residual bone dust
from the drilling should be irrigated away from the hole
before screw application. The act of tapping itself creates
additional bone dust as the threads are cut This material
can lead to binding and excessive wear of the threads. 1he
bone dust should be released by intermittent back turns
while tapping and irrigated away. Some syJtems require or
offer as an option tapping as a separate step.1he tap thread
must match the screw threads exactly, and the subsequent
screw must be placed carefully to aroid cross-threading. If
inadequate bone exists around the drill hole to hold the
screw, then it will fail to tighten as it is screwed into the
bone and will begin to slip. Overtightening of the screw
can lead to microfracture or stripping of the bone threads
as well. Because this is a fairly frequent occurrence, most
plating systems contain emergency (rescue) screw!, which
are screw! with the same shaft diameter but a greater
thread diameter to allow for bone engagement beyond the
stripped portion of the hole. If the emergency screw fails
to engage, then another fixation site must be sought. If the
plate has cma holes beyond what is needed for adequate
:fixation, the stripped screw or ...spinner may still be useful.
1hat screw can be left in to anchor the reduction and plate

A lag screw presses two pieces of bone together by compressing the :first piece of bone between the second piece
in which the tip of the screw is engaged and the head of
the screw (Fig. 78.5). In this situation, a hole is drilled relatively perpendicular to a fracture line t:rave11ing the fracture. 1he hole is double drilled such that the part of the
hole on the screw head side of the fracture matches the
diameter of the screw with threads, allowing the screw to
glide or to be pushed through the hole to the fracture. On
the other side of the fracture, the hole diameter is drilled
to match the screw shaft diameter without threads. This
allows the screw threads to engage the bone on the other
side of the fracture. As the screw is tightened, the top fragment is compressed between the head of the screw and the
second fragment in which the threads are engaging on the
other side of the fracture. An enhancement of this technique has occurred through the development of a tapered
drill bit. This bit allows a single drilling motion to provide
a larger gliding hole on the screw head side of this fracture
and a smaller engaging hole on the other side of the fracture. Because of the often near-tangential angulation of the
screw relative to the cortical surface, a countersink hole is
drilled to allow the screw head to seat better. Sometimes,
drilling the countersink hole :first facilitates drilling for the
lag screw. The countenlink hole should not be too deep or
the screw head as it is tightened will pull through the residual cortex. into the marrow space and will not be stable.
It is very important to distinguish a lag screw from a
positioning screw: A positioning screw is used in very specifi.c circumstances such as fixation of a mandibular sagittal
split osteotomy. There, lag screw compression may overcompress the mandibular neurovascular bundle or overtotque the condyle. When a position screw is desired, the
drill holes on either side of the fracture or osteotomy are of
the screw shaft diameter without thread. The screw threads
then engage the bone on either side, making compression
across the fracture impossible. The bone segments are fixated into position relative to each othe:t but a gap exists
between them, and there is no compression.

PLATE APPLICATION
A myriad of plate dimensions and shapes exists that conform to multiple anatomic applications ( 14) (Table 78.1).
lhe variety allows the surgeon to maximize the number

1158

Section V: Trauma

Countersink

Gliding hole:
hole diameter equal
to outer thread diameter

Bone

Biting hole:
hole diameter equal
to inner core diameter

Fig... 78.5 A: Drilling gliding hole for lag screw plaa~ment. The diameter matches the outer screw thread diameter.

B: Drilling biting hole for lag screw placement. The drill bit diameter matches the Inner core diameter of screw. C: Detail
of lag sc:n~w. Diameter of bone hole dosest to the head of the screw matches the outer diameter of the threads of the
screw, allowing the screw to be pushed through or glide through the first hole without being turned. Diameter of the
hole dosest to the tip of the screw matches the Inner core diameter of the screw. When the screw Is tightened, the two
pieces of bone are compressed together.

of fixation points in solid bone while minimizing potential injury to underlying structures and working through
sometimes difficult exposures. At least two fixation points,
one on either side of a fracture, are required for a plate

RECOMMENDED PLATE
APPLICATIONS
Plate Size
Skull/frontal sinus/supraorbital
rirns/nasoethmoid complex.
Lateral orbital rim
Inferior orbital rim
Piriform aperture

Posterior max.illary buttress

Mandible

Mandible with comminution,

infection, or defect

Microplates/3-D microplates
Microplates or low-profile
miniplates
Microplates
Low-profile, standard, or 3-D
max.illary miniplates or 3-0
microplates
Standard or 3-0 maxillary miniplates or 3-0 microplates
Mandibular (thicker than maxillary) miniplates, standard mandibular plates (DCP or EDCP),
3-D mandibular miniplates
Reconstn~ction plates

In any location, depending on the situation, wires, h&IIY}' sutures, or no

fiXation at all may be appropriate.
DCP. dynamic oompression plate; EDCP. &ClCGntric dynamic compres-

sion plate.

to function as a tension band (resisting distraction forces

only). Howevet there is no rotational stability with two
points of :fixation. Three points of fixation. two screws on
one side of the fracture and one on the othe:t;. will prevent
plate rotation. Ho~ the fragment with only one point
of :fixation would still have rotational instability. Four
points of:fixation, two on either side of the fracture, should
be the minimum goal for providing stability of the plate
and both fragments. Additional fixation points up to five
or six on either side of the fracture may be desirable when
bony defects are bridged or healing complications are present. Compression or loading of the bony segments aCI'088
a fracture, as mentioned before, increases stability. this
compression can be provided before plate application by
compressing the segments together with a forceps such as a
modified towel dip or by the plate itself.

INSTRUMENTATION
Application of plates and screws to bone requires specialized instrumentation. l}'pically, plating systems are
self-contained in that they provide all the specialized
instrumentation needed for application of the plates.
Standard instrumentation for obtaining exposure of the
fracture site, howeve:t;. is not included. Scalpels, scissors,
clamps, retractoD, and periosteal elevatoiJ typically mwt
be supplied in addition to the plating set.
The plating set itseH has drill bits that are precisely
matched to the screw size. As previously mentioned, a

Chapter 78: Principles in Rigid Fixation of the Facial Skeleton

hole that is too large will prevent the screw from engaging
the bone. A hole that is too small may prevent adequate
driving of the screw 01; in the case of microsystems, cause
shearing of the head off of the screw shaft as it is being
driven. Typically, there is only one appropriate drill bit
diameter for a given screw diameter, and it is usually the
size of the screw shaft (i.e., the screw without its threads).
An exception to this is found in some microplating systems
where drill bits of two different diameters are appropriate for one particular screw diameter. The larger drill bit
is used in areas where the bone is harder and thicker to
reduce screw head shearing. A smaller bit is used where
the bone is thinner or softer, particularly in pediatric cases,
to increase screw thread hold. Drill bits with stop collars allow for drilling of a hole to a predetermined depth.
The collar prevents overpenetration of the bit protecting
underlying structures.
Drill guides serve several purposes. They protect the surrounding soft tissue from injury by the rotating drill bit
and allow for percutaneous drilling. The guide also serves
to stabilize the rotating bit, allowing a more precise drill
hole. Additionally, guides provide for more precise placement of a drill hole relative to a plate hole. Concentric drill
guides place the drill hole in the center of the plate hole.
Eccentric guides place the drill hole off center, allowing for
compression as the screw head seats in the center of the
plate hole. An addition is a guide with a curved extension
that points to the drill bit exit site for through-and-through
drilling. This extension allows more predictable drilling.
Depth gauges allow precise selection of an appropriate screw length for a given application. When bicortical
fixation screws or lag screws are placed, the screw should
be long enough to engage the inner cortex without protruding more than a millimeter or two beyond the cortex.
When monooortical screws are being placed, the surgeon
should have a general idea of the appropriate depth before
drilling to avoid damage to underlying structures before
a screw is ever placed. For example. monocortical screws
being placed over tooth roots should not be longer than
3 to 5 mm depending on location, and the drill hole should
not be drilled any deeper than this. Drill bits with collared
stops predetermine the drill hole depth and allow appropriate screw length selection without a depth gauge. When
tapping is a separate step, the depth gauge should be used
before tapping to avoid damage to the threads in the bone.
Some systems contain bone reduction forceps that
allow fracture reduction and/or temporary fixation while
plates are being bent and applied. Some of these devices
are designed to apply compression across the fracture.
These devices are useful because they make it possible to
avoid having to continually rereduce the fracture for testing of plate contour, which may result in a less precise
final reduction and fixation. The bulkier devices require an
extraoral approach. Towel, Kelley, or Kocher damps often
will suffice. Drilling of small holes flanking a fracture will
sometimes improve the purchase of reduction damps.

1159

Wires can be passed through drill holes on either side of

the fracture away from the area needed for plating and
used for temporary reduction. Incompletely driven screws
can be placed on either side of the fracture and wired or
damped together for temporary reduction.
Various screwdriver tip and screw head configurations
exist, and the interface between the two is the important
factor. Ideally, the interface provides sufficient strength
(i.e., resistance to stripping) so that appropriate torque can
be applied to drive the screw into the bone. The interface
should also allow retention of the screw on the tip of the
driver while it is being brought into position. This retention is achieved in several ways. One is through friction at
the interface. The other is for a damping mechanism that
slides down the screwdriver shaft and grips the edges of the
screw head. This damp device can be too bulky for working
through percutaneous instrumentation and in other tight
locations. Bone wax on the tip of the screwdriver is a third
option when the damp is too bulky and interface friction
is inadequate for screw retention. Additionally, the interface
affects how quickly the screw can be mounted on the driver,
an important factor in dealing with multiple fractures and
long repair procedures. It is also important to know what
screw type is present when removing hardware so the appropriate screwdriver can be available. Some manufacturers now
have screwdriver sets containing all of the common types.

FRACTURE REDUCTION
The structure of the facial skeleton can be viewed as a lattice framework of thick bony buttresses that impart the
3-D strength necessary to withstand the functional forces
of mastication (Fig. 78.6). The intervening thin bone adds
little additional strength but serves as a partition separating various facial components such as the sinuses, omits,
pharynx,. and nasal and cranial cavities. Reestablishment of
the anatomic position and continuity of these buttresses
is the key to fracture reduction (15). Although of secondary importance. anatomic reduction of the intervening thin
bone should be obtained as well, particularly when that
bone forms one of the walls of the orbit. Otherwise. oroital
contents will sag through the defect into an adjacent cavity,
resulting in globe malposition.
Anatomic reduction predisposes a frame of reference
that guides the replacement of a malaligned bony fragment
into an aligned position. With massive facial trauma, anatomic reference points may be further away and more difficult to expose and/or they may be so comminuted that
they cannot provide a reliable indication of the proper
reduction. For example. in a simple zygomaticomaxillary
complex fracture. the medial aspect of the infraorbital rim,
the superior aspect of the lateral orbital rim, the zygomatico-sphenoid relationship in the lateral orbit and the
posterior maxillomalar buttress provide adequate reference
points for anatomic reduction. Panfacial fractures resulting
in comminution or mobility of these reference points may

1160

Section V: Trauma

Figure 78.6 14:. Facial skQieton show

lng bony buttresses with removal of In
tQrvenlng bone. B: Repl'Qsentatlon of
structural buttressing of the mldfaCQ.

necessitate exposure of the root of the zygomatic arch as

another reference point for appropriate placement of the
zygomaticomaxillary complex (16). Preoperative virtual
surgical planning systems and intraoperative 3-D positioning systems offer some promise in aiding with this problem (17-22).
High-eneJgY injuries may lead to sevae comminution
or even pulverization of intervening segments of bone.
In this cas~ bony structure is reduced to its anatomic position based on existing :reference points, and intermling
gaps in the but:lreSSeS are bone grafted. Reestablishing bony
continuity of the butttesses is imperative because they must

ultimately trnnsmit the foit:es of mastication to the skull

base. Sometimes, a bony fragment from a less audal area
can be bol'ro'M!d and reoriented to establish buuress continuity. Frequently, additional bone is required, howev~ and
outer table calvarial bone is our preferred source for bone
grafting because of its reliability and proximity to the injury
site (Fig. 78.7). Minimal donor site morbidity and frequent
preexisting exposure due to use of the coronal approach to
the face are benefits. Other relatiwly popular donor sites
include the ilium and ribs. Hydroxyapatite cement offers
promise for dealing with bony defects without attendant
donor site mOibidity particularly when :fiber reinforced (23).

Figure 78.7 In situ technique of outer table calvarial bone harvest. 14:. Location of donor sit"
on parietal skull. B: Saua~rizatlon of bone around graft. C: Cross-sectional view of saua~rizatfon.
D: Calvarium split with angled saw. E: Calvarium split with redprocat:lng saw.

Chapter 78: Principles in Rigid Fixation of tite Facial Skeleton

OCCLUSION
For the masticatory apparatus to function properly, stable
reproducible occlusion must exist For occlusion to ocau;.
the 01Sps of the maxillary dentition must fit into the groava
of the mandibular dentition and vice versa (Fig. 78.8).
1his is termed interruspation. Wear facets of opposing
teeth should contact each other. The wear patteml!l may
be the only reference when preinjur:y occlusion b abnormal. Normal molar occlusion in the anteroposterior (AP)
dimension is defined as intercuspation of the mesial buccal OJBP of the maxillary first molar with the buccal groove
of the mandibular fust molar. This description does not
address transverse molar relationships or anterior dental
relationships. A normal transverse relationship exim when
the buccal cusps of the mandibular molars are between the
buccal and palatal cusps of the maxillary molars. Normal
anterior dental relationship occurs when the maxillary

1161

anterior dentition b 1 to 3 mm anterior to the mandibular anterior dentition with central incisal overlap of 1 to
3 mm. Increased distance horizontally between the incisors is CM!Ijet. Increased vertical distance is overbite or
deep bite. Anterior crossbite and anterior open bite are the
respective converse conditions.
Because preinjury occlusion is frequently not normal
as defined previously, it is useful to question the patient
or family about the preinjury occlusion. Dental records
are also quite helpful. In the absence of this information,
~ar facets are the main occlusal guide. When the preinjur:y occlusion is unclear, then anatomic reduction of the
fractures before interdental :fixation may be more accurate.
There should be no reluctance to open interdental fixation
if it is preventing anatomic reduction of bone segments.
The interdental :fixation and skeletal reduction should correlate. If they do not. a preexisting malocclusion should be
suspected.

Class I

:Horizontal) overbite,
:vertical)

Posterior
crossbite

Figure 78.8 A:. Various anterior Incisal relationships. 1, normal; 2, overjet and overbite; 3, edge to
edge; 4, anterior aossblte or underblte; 5, anterior open bite. B: Transverse relationships. 1, normal;
2, bilateral lingual aossblte; 3, bilateral bucxal crossblte; 4, unilateral lingual crossblte. C: Sagittal
molar dass relationships. 1, dass I; 2, dass II, division I; 3, dass II, division II; 4, dass Ill.

1162

Section V: Trauma
any situation requiring a heavy plate placed posteriorly on
the mandible should be approached exttaorally through
a Risdon and/or submandibular neck incision. Low subcondylar fractures needing repair can be approached transorall:y, but this requires specialized equipment. Unless
endoscopic techniques can be utilized, high subcondylar
fractures needing repair will require either a Risdon, retromandibulat;. or a preauricular incision (27-29).
The inferior maxilla can be exposed through a superior circumvestibular incision. The superior exposure can
be extended by elevating the nasal floor mucosa between
the inferior tu:rbinate root and maxillaxy crest Even further
superior exposure can be obtained by incising the nasal
mucosa along the cephalic border of the lower lateral cartilage and piriform aperture in a full midface degloving
approach. Pitfalls include damage to the infraorbital nerve.
nostril stenosis, and leaving inadequate oral vestibular
mucosa for wound closure.
Upper facial access can be obtained through a coronal
incision elevated in the subgaleal or subperiosteal plane.
This incision provides access to the medial, supe:riot and
lateral walls of the orbit; the zygomatic arch; and the bony
pyramid of the nose. It additionally uncovers donor sites
for cranial bone grafting. Pitfalls include damage to cutaneous senso:ry innervation and motor innexvation to the

INCISIONS AND EXPOSURE

Adequate anatomic reduction requires wide exposure to
view fractures from seftl'al angles. Laceratiom may provide some exposure. but frequently more is needed. The
entire craniofacial skeleton can be exposed through a combination of hidden or well-camouflaged incisions (24)
(Fig. 78.9). The entire mandible except for the condyles can
be exposed through intraoral vestibular sulew1 incisions
(25) (F"tg. 78.10), and now, with the addition of endoscopic
techniques, even the condylar area can be adequately
exposed transorally for endoscopic-assisted repair (26).
Small stab incisions through. the cheek may be necessary
for plating posterior fractures and subcondylar fractures;
however, angulated instrumentation promises to reduce the
need for even these incisions. Pitfalls associated with the
mandibular vestibular sulcus incision include damage to
the mental nel'ft'. failure to achieve a watertight closure of
the incision, and failure to resuspend the mentalis muscle if
the chin is degloved. Intraoral incisions for the mandible
are not recommended with comminuted fractures, severe
periodontal disease, or hygiene problems. Because of the
tangential view achieved when approaching posterior fractures ttansorall:y, it can be veJ:Y difficult to contour a heavy
plate to the outer corta. It is our recommendation that
A

pericranium
Reflected
periosteum
of zygoma

Subperiosteal --r--.,.,.n
incision

Figure 78.9

A; Cranloorbltal &lCpOSUre 1hrough

blcoronal flap. B: Mldface exposui'Q through d!'>
cumwstlbular Incision.

Chapter 78: Principles in Rigid Fixation of tite Facial Skeleton

1163

Figure 78.10 A:. Intraoral approach to the arrterlor mandible. 1: Intraoral approach to the angle
of the mandible.

frontalis muscle or inadequate closure of the galea. both of

which can lead to brow ptosis.
Infrao:rbital rim and o:rbital floor exposure ia still limited, howevet and a lower lid incision is required for
that exposure. We prefer either a subcilicu:y incision or a
transconjunctival incision with or without a lateral canthotomy and inferior cantholysis for increased exposure
when necesscu:y. Inferior lid crease and rim incisions are
other options in this area, although they are rarely used
today. Careful closure of these incisions and canthal repair
are critical to reduce lid complications of entropion or
ectropion.
If a coronal incision is not performed, then access to the
frontozygomatic region can be obtained through a lateral
brow incision or a superior lid crease incision (12). Medial
orbital wall and nasoethmoid exposure can be obtained
through a broken atcmal ethmoid-tJpe incision. Some
people use a gull-wing incision. but the scar can sometimes
be quite unacceptable. If the nasal do:rsal skin between the
incisions is sufficiently elevated and mobilized, then adequate exposure can usually be obtained by retracting the
skin without having to make the transverse incision across
the nasal dorsum. A transcaruncular incision may provide
adequate access to the medial o:rbit (30).

APPROACH TO PANFACIAL FRACTURES

Severe and complex facial disruptions represent difficult
challenges for the craniomaxillofacial surgeon, because
usually few reference points are available to help the surgeon determine how to reposition the multiply fractured
fragments. Nonetheless, the principles of repair remain the
same, and careful attention to the procedures described
previously will lead to the best possible outcomes.

Emergencies related to massive facial trauma must be

attended to :first (Table 73.2). The airway can be threatened by anatomic obstruction. blood, or both and must be
secured. Gross hemorrhage must be controlled, preferably
with direct pressure. Definitive control should be obtained
in the operating room to prevent damage to important
nonva~Jcular structures. Occasionally, partial reduction of
severely displaced fractures is n.ecessazy to aid in the control of hemorrhage. A few interdental wires can be placed
emetgendy to stabilize this gross reduction and alleviate
some of the pain associated with mobility of the fractures.
Soft tissue injuries should be irrigated and repaired if the
patient is not planned for immediate fracwre repair in the
operating room. Dental avulsions and fractures through
the pulp cavity should be treated wgently if the damaged
teeth are to be salvaged, and other dental injuries should
be identified and appropriate consultations obtained {31).
Preoperative antibiotics have been shown to reduce infectious complications (32). Tetanus should be considered in
grossly contaminated wounds.
Histoty and physical examination can provide some
initial indication of the extent of facial injuries. Historical
information such as mechanism of injw:y and enagy
of impact is useful in assessing the extent of the injury.
Ecchymosis patterns including raccoon eyes and Battles'
sign can be indicative of skull base fractures. Other soft
tissue findings such as the bowstring lid test can indicate
canthal detachments. Palpation of bone surfaces will allow
detection ofstep-of& and mobility. Documentation of cranial
nerve function is critical to distinguish injw:y-associated
deficits from iatrogenic deficits occurring after fracture
repair. Other factors such as neurologic and visual function
are frequendy impaired with panfacial fractures. Neurologic
and ophthalmologic assessments are necessary (33).

1164

Section V: Trauma

EMERGENCIES
FACIAL TRAUMA

Situation

Intervention

Airway obstruction
Hemorrhage

Intubation, tracheotomy, bronchoscopy

Fluid resuscitation, direct pressure, temporary reduction of
severely displaced fractures, control in operating room,
fluid resuscitation

Central nervous system injury

Cervical spine
Brain
Reimplantable avulsions
Tooth
Large areas of soft tissue
Globe rupture
Optic nerve compression

Immobilize
Neurosurgery evaluation
Reimplant and stabilize
Reimplant microvascular reanastomosis hyperbaric
oxygen treatment
Ophthalmology evaluation, repair or enucleation
Medical management
Surgical decompression

Radiologic evaluation is key to the full assessment of

massive facial trauma (34,35). In our institution, axial
computed tomography (Cf) is obtained as part of the
initial trauma protocol when head and facial injuries are
present. Because of cervical spine clearance issues, acute
direct coronal CIS are rarely obtained. If complex periorbital fractures are present, then when the patient's condition permits, direct coronal cr is obtained. The mandible
is separately evaluated with plain radiographs and panoramic radiography if the patient's condition permits. cr
evaluation of the mandible provides additional information as well (36). With severe injury, 3-D reconstructions
may be helpful.
With severe craniofacial injuries, there is a high risk that
injuries may involve the eyes, dura,. and neural structures
of the skull base and cervical spine. It is essential that the
surgeon be attuned to these possibilities, because failure
to recognize these associated injuries could have dire consequences for the patient Globe injuries must be evaluated by ophthalmology. Ruptured globes often require
enucleation, although occasionally minor ruptures may be
repaired, and this situation may mandate postponement
of the repair of the orbital/periorbital fractures. Similarly. a
retinal detachment may require a period of healing before
surgical manipulation of the surrounding bones.
It is critically important to identify optic nerve compression, because rapid and aggressive management of this
injury may preserve or even salvage vision. When optic
nerve compression is associated with frontonasal fractures of the anterior skull base, the subcranial approach
as advocated by Raveh et al. (37,38) provides excellent
access to the optic nerve canal(s) for decompression. In
the subcranial approach, the nasal bones and front wall of
the frontal sinus are removed en bloc and saved for later
replacement The posterior wall is then opened, allowing

full visualization of the anterior cranial fossa without

olfactory compromise or significant brain retraction. This
approach also allows for the repair of associated skeletal
injuries in the anterior skull base, medial orbits, frontal
area, and nose. Rigid fixation allows for the dependable
repositioning of the bone fragments and thereby makes
the subcranial approach possible. Without rigid repair
of the completely removed nasofrontal bone fragments,
there would be a high probability of malposition and/or
resorption of the bone. Most authors advocate a trial of
very high-dose steroids before optic nerve decompression
is attempted (39). An eye that shows no light perception
from the moment of impact is probably irretrievable, and
the value of decompression in this situation is controversial at best. On the other hand, if a patient has progressive
visual loss or if a seeing eye progresses to no light perception after trauma to the area of the posterior orbit and/
or anterior skull base, and if steroids are not effective in
restoring vision within 24 to 48 hours, then most authors
would agree that the potential benefit of optic nerve
decompression probably outweighs the risks. If the subcranial approach is not appropriate (or desired), then the
optic canal can be approached endoscopically through the
sinuses or from above via an intracranial approach (40).
Recently, some periorbital endoscopic approaches have
been described that show promise.
When the floor of the anterior fossa is disrupted, then
it is convenient to perform the repair at the time of facial
fracture reduction. Here again, the subcranial approach
provides excellent access to this area (38). It allows for
repair of the anterior fossa dura with a fascial patch or a
pericranial flap, without the need to significantly elevate
or retract the frontal lobes. This is a very desirable feature
of the technique. In most of these panfacial fracture cases,
the brain has been injured and is likely to be swollen.

Chapter 78: Principles in Rigid Fixation of tite Facial Skeleton

Nasal process
of frontal bone

1165

Nasal septum
(perpendicular plate of ethmoid)

Ethmoidal labyrinth
*--~~---,

Lamina papyracea
(of ethmoid bone)

Zygomatic

process of
Glenoid
fossa

'Iherefore, acute repair should be considered to decrease

the likelihood of cerebrospinal fluid leakage and thereby
decrease the risk of later development of meningitis. The
subcranial approach avoids brain retraction due to the
inferior and direct angle of approach. making early intervention a feasible option in this circumstance.
With regard to timing of repair of fracture~~, unleas a
patient's overall condition prevents it. immediate repair
has been advocated as the best approach (41). Immediate
repair allows visualization of facial structure~~ before the
full development of injury edema. which generally occurs
24 to 48 hours after the injury. Howev~ associated injuries &equendy require several days for stabilization of the
patient (42). Delaying repair may lead to increased bacterial contamination and therefore increased risk of infection. With further delay, the soft tissue envelope around the
fractured skeleton begins to fibrose and contract,. increasing resistance to anatomic reduction. With increased delay,
callus formation and resorption of some of the fine detail
of the fracture edges increases the difficulty of mobilization
and reduces the ability to achieve an accurate reduction.
As previously stated, one of the major problems with
massive facial tmuma is a lack of reference points for
anatomic reduction. Approaches yielding wide exposure
are preferred (43) although there has been a recent trend
toward less invasive approaches (44-47). With maximal
exposure of the facial skeleton, repair should begin at the
periphery, including recreating the contours of the skull
and the mandible. The ultimate reference for facial skeletal position is the skull base (Fig. 78.11). For the mandible, this reference is through the condylea. Therefore. the
importance of open reduction of subcondylar fractures in
this situation cannot be overemphasized. For the middle

temporal
bone

Figure 78.11 Skull base detail

showing maJor areas of attachment
of the facial skeleton to the cranial
skeleton. These indude 1fle nasal and
zygomatic processas of the frontal
bone, the zygomatic process of the
temporal bone, the nasal septum, and
the pterygomaxlllary junction.

and upper face, the vertical reference points are the lateral
and medial o:rbital rims, the nasal radix;, the piriform apertures, and the posterior maxillary buttresses. Often underutilized is the important horizontal AP reference along
the zygomatic arches. Anterior skull fractures can obscure
some of these reference points, but then, the nat higher
point of skeletal stability becomes the new reference point.
Once anterior skull fractures are repaired, facial fracture
repair can proceed. A systematic approach working from
areas of stability toward areas of instability is required. All
fractures that are to be repaired should be exposed and
reduced before any :final fixation. Vertical, horizontal, and
sagittal facial dimensions must be restored (Fig. 78.12).
We often prereduce complex fractures with wires or sutures
initially, withholding more rigid fixation until all fractures
have been adequately reduced. Maxillomandibular interdental fixation should be achieved before skeletal fixation
as well. Release of maxillomandibular fixation may be
required to effect anatomic reduction of bony segments,
partirularly when preinjury occlusion does not appear to
have been normal. Cutting an arch bar over an area where
a fracture proceeds between ~th may also be required to
achieve anatomic bony reduction. The split arch bar is then
repaired once reduction is obtained.
Typically, fracture fixation proceeds cennipetally toward
the nasal region (centripetally) (Fig. 78.13), although
some advocate starting with the nasoorbitoethmoid region
(centrifugally). Skull fractures, frontal sinus fractures, and
any intracranial injuries are addressed :first A subcranial
approach as previously mentioned through the nasofrontal region is our preferred method to acass the anterior
cranial fossa and medial orbits when the anterior skull
base is involved. The mandible should be repaired, and

1166

Section V: Trauma

Width

FiguN 78.12 Important dimensions of 1he facial skeleton to be

reestablished during rec:onstl'\lctive efforts.

if necessary defects should be bridged with reconstruction plates. Whether the mandible is severely comminuted
or partially absent, the occlusal relationship remains the
priority concern and the best indication of the premorbid shape. When the dentition is lost or absent, occlusion
becomes less critical and obviously unusable as a landmark Mandibular height should be reconstituted, using a
costochondral graft to reestablish the condylar position if
the condylar head has been lost In the case of bilateral displaced subcondylar fractures and midface fracwres, at least
one of the subcondylar fractures will need to be opened
and internally fixated to provide a reference for lower third
facial height If necessary, zygomatic arch fractures are
then fixated to provide an AP reference for the malar eminence (48). Arch repair is performed using wires whenever

Figure 78.13 14:. Panfadal fractures. B: Repair of frac

tures with rigid flxatlon. Fractures are typically repaired
cantripetally, working from the skull base and the man
dlble toward the mldfac.e and working from the lateral
mldfac.e toward the mtildlal mldfac.e.

possible, because even small plates on the arch may create

some broadening of the cheek If plate fixation is needed,
the smallest (thinnest) plates available should be used. In
rare cases, this may require bone grafting of one or both
malar eminences to reestablish the proper facial projection. The maxilla and its dentition can then be suspended
rigidly from the zygomas, using plates and/or bone grafts
to ensure fixation and bony continuity. Lateral maxilhuy
buttress, piriform aperture, and lateral orbital rim fractures
are then repaired. Then the o:rbital rim contours are reconstructed, trying to recreate the natural shape of the orbits
with bone grafts or implants while making sure that the
globes are returned to their proper position with a 2- to
3-mm overcorrection to allow retropositioning as swelling decreases. Note that the vertical position of the globe
should not be ove:rcorrected. Any buttresses with segmental defects after appropriate reduction of the skeletal structures are bone grafted. The bone grafts are stabilized and
positioned with bridging plates and/or screws. Once buttress continuity has been reestablished, remaining lamellar
bone defects are addressed as needed. The bimalar diameter can usually be reestablished based on the posterior buttresses after occlusal relationships have been reestablished.
With severe comminution. howeve~;. repair of the nasoethmoidal complex provides additional reference information
for restoration of the bimalar diameter. Recent advances
include the use of rapid prototyping, which allows for
the use of prefabricated implants (49), and the use of a
sterilized skull model to allow for plate adaptation (50).
In addition, the advent of image guidance systems has
allowed for careful planning and carrying out of complex
facial repairs (17). Swgical planning can be carried out at a
worbtation preoperatively, and then a wand can be used at
swgety to identify the positioning of bone fragmenta and
grafts relative to the desired positions ( 17).
O:rbital floor continuity must be reestablished. We prefer autogenous bone for this rep~ although some prefer

Chapter 78: Principles in Rigid Fixation of the Facial Skeleton

alloplastic implants for this location; this is clearly a controversial issue. The previously mentioned titanium anatomic orbital plates and titanium polyethylene composite
plates are becoming popular. Perpendicular plate of ethmoid and/ or septal cartilage, if not severely fractured, can
be used to replace the orbital floor, walls, or roof. Cranial
bone or the nonfractured anterior face of the maxilla also
do well here. Very small defects can be covered with absorbable plates, gelatin film, or homograft dura. The superior,
medial, and lateral orbital walls need to be repaired if they
are displaced enough to impinge on orbital contents or significantly alter orbital volume. A defect greater than 2 to
3 em in diameter of the anterior face of the maxilla itself
may need to be repaired; otherwise, facial soft tissue will
collapse into the sinus, creating a subtle but noticeable
deformity of the melolabial region.
F'mally, the nasoethmoid complex is addressed. The typical telescoping collapse must be reduced and reprojected.
Frequently, the lamina papyracea needs to be replaced with
bone grafts to support forward projection and prevent the
herniation of periorbita into the ethmoid sinuses. It is also
important to create a structure against which the medial
canthal ligament can reattach after fixation. The projection
of the nose is reestablished by cantilevering off the frontal
bone andfor fixation of the medial orbital region. If the
nasal dorsum is deficient, a primary bone graft should be
placed.
Once complete fracture reduction has been achieved,
certain soft tissue structures that were detached traumatically or to provide exposure must be resuspended. The
medial and lateral canthi should be suspended from the
adjacent bone slightly posterior and superior to their original insertion sites either with wires or heavy nonabsorbable sutures. For medial canthal suspension, a permanent
suture may be utilized. It is placed through the ligament;
passed through the nasal septum, lamina papyracea, and/
or drill holes in the medial orbital wall bone grafts; and positioned so that the ligament is pulled posteriorly and superiorly. The medial tension is then adjusted using the suture,
which is fixed to the contralateral frontal bone using a
plate hole, a screw, or a hole drilled through the medial
supraorbital rim.
As previously mentioned, the mentalis muscle should be
suspended from drill holes in the menton. Soft tissue of the
midface might need to be resuspended too if it was significantly dissected. The lacrimal ducts should be cannulated
if they are interrupted or do not flow freely when irrigated.
Access incisions must be closed meticulously to prevent
complications. Failure to close the galea in the bicoronal
incision can lead to brow ptosis. Failure to obtain watertight closure of intraoral incisions can lead to dehiscence
and plate exposure. Particular attention should be paid to
the lower lid incision closure to prevent entropion or ectropion. A Frost stitch should be placed through the lower lid
and fixed under tension to the forehead (with tape). This is
left in place for 24 to 72 hours, to stretch the lower lid.

1167

SOFT TISSUE LOSS

The acute repair of soft tissue loss remains controversial
when dealing with facial injuries. Of course, whenever
it is feasible, it is preferable to repair soft tissue loss and
bone loss simultaneously. In years past. early attention
was directed at restoring the soft tissues, with the belief
that the primary repair of the facial skeleton could not be
successfully performed in the absence of adequate soft tissue coverage. Unfortunately; in the absence of proper skeletal support,. reconstructed soft tissues often shrank and
retracted, leading to the development of contractures that
frequently interfered with the ultimate hard-tissue reconstruction, and a satisfactory outcome was less likely to
result.
The advent of rigid skeletal fixation has allowed for a
rethinking of this approach, because rigidly fixed bony
structures will generally survive even in the absence of
adequate soft tissue coverage. This has proved particularly helpful in shotgun-blast injuries, which can be very
destructive to both skeletal and soft tissues. An example is
shown of the case of a stainless steel mandibular reconstruction plate that was placed across a shotgun-blast
defect of the anterior mandible (Fig. 78.14). The defect
extended from midbody to midbody. Deltopectoral skin
was used to incompletely cover the steel plate. (Note that
this approach could not have been considered before the
introduction of rigid fixation techniques, because mobile
exposed bone fragments often become infected and
necrosed.) Ultimately; after release of the flap and closure
of the soft tissue defect. the space (which had been maintained by the reconstruction plate) was reconstructed with
an iliac corticocancellous graft that was fixed to the plate.
The graft took completely, and the plate was later removed,
leaving fully recontoured mandible.
The same principles have been similarly applied to midfacial defects. The availability of microvascular free tissue
transfer has made it possible to perform immediate soft tissue and/or skeletal reconstruction oflarge defects when the
patient's condition is appropriate. Restoration of the skeletal framework (or its shape) should be accomplished as
acutely as possible. Although the soft tissue reconstruction
is now generally performed acutely when possible, it can
be delayed if necessary due to the needs of the individual
patient and/or the techniques available for repair.

COMPLICATIONS AND REVISIONS

With severe injuries, it is not uncommon to obtain a less
than perfect result, though an excellent reconstruction is
often acceptable to patients who appreciate the severity
of their initial injuries. Still, selective revision surgery can
enhance an outcome and convert an acceptable result to
an excellent one. The judicious use of bone grafts or alloplastic implants may be necessary to build up deficient
areas or reposition a globe. Occasionally; a malunion may

1168

Section V: Trauma

D
Figure 78.14

Patient with midfacial shotgun-blan injury after soft tissue repair. 1: Initial maintenanat of mandibular spacing with reconnruc:tion plate. C: Bony continuity reenabli,hed with
graft, and plate removed. D: Result after additional soft tissue surgery.
A;

result. and one of the options available is the remobilization of facial bones via osteotomy followed by repositioning and re:fi:J:ation with bone grafts as needed. The
techniques for this are beyond the scope of this chaptet
but it is important to offer this option to a patient with a
residual deformity.
It is not Wlcommon for craniomaxillofadal sutgeons
in tertiaJ:y care centers to receive referrals of patients
who have already undergone initial and sometimes subsequent repairs. OCOllJionally, patients have not been
repaired at all for a variety of reasons. It is important for
the tertiary surgeon to avoid judgmental commenwy

and focus on what can be offered to the patient 1hese

are challenging cases both technically and emotionally,
and they should be approached with the utmost skill and
diplomacy.
A host of complications may be seen, including ectropion, entropion, facial scarring, epiphora. numbness, facial
nerve injuries, diplopia. malocclusion, facial asymmetty,
and temporomandibular joint dysfunction (Thble 73.3).
Familiarity with the multiplicity of problems and outcomes that can result will make it possible for the facial
plastic swgeon to offer the patient the widest variety of
options for care.

Chapter 78: Principles in Rigid Fixation of the Facial Skeleton

1169

'Ill COMPUCAllONS
.... FACIAL TRAUMA
Type

Management

Osseous

Osteitis
Delayed union
Osteomyelitis
Nonunion
Malunion/mal occlusion
Fibrous union with poor function
Bone loss
Temporomandibular joint dysfunction

Soft tissue
Deficiency
Scarring
Ptosis
Lagophthalmos
Entropion
Ectropion
Nasal obstruction

Intravenous antibiotics
Observation, prolonged interdental fixation
Intravenous antibiotics :1:: hyperbaric oxygen,
debride and revise
Debride and revise
Osteotomize and reposition
Debride and revise
Free bone graft revascularized
Etiology specific
Local/regional/distant tissue transfer
Scar revision, Iaser resurfacing, etc.
Etiology-specific ptosis repair
Scar revision, weights, springs
Lid revision, free grafts
Lid revision, free grafts
Septoplasty, lysis of synechiae, valve surgery

Neurosplanch nic

Brain injury
Globe injury
Globe malposition
Cerebrospinal fluid leak
Meningocele/encephalocele
Cranial nerve dysfunction
Glandular dysfunction

Management of massive or complex injuries

follows the same principles used for less severe
injuries.
Anatomic reduction of fractures offers the best chance
of return to preinjwy function and appearance.
Rigid internal fixation stabilizes and shields a
reduced fracture from biomechanical forces that
would act to displace the fracture until bone healing
can occur.
Fracture repair is best achieved as early after the
injury as possible with the following being considered: the patient's overall condition takes priority
and maximal soft tissue swelling occurs 24 to
48 hours after the injury.
Within limits, the stability of an internal fixation
system increases with the rigidity and thickness of
the material, the size and number of screws, the
thickness of the underlying bone. and compression
of the fracture edges.

Per neurosurgery
Per ophthalmology
Orbital bone grafts/repositioning
Endoscopic or open repair
Surgical repair
Compensatory procedures
Artificial tears/saliva
Punctal plugs

Application of a screw to be a successful fixation point

for a plate requires maintenance of a healthy cylinder
ofbone lining the drill hole that "hugs" the inner shaft
of the screw as it or a tap cuts threads in the bone.
Plate type and location selection is made to provide
adequate stability to a fracture while minimizing
application difficulty, hardware load, and prominence
through the soft tissue.
The 3-D skeletal buttress structure and continuity must
be reestablished to restore facial appearance and the
ability to withstand biomechanical forces.
Resuspension of key soft tissue structures such as the
medial and lateral canthi and the mentalis muscle is
necessary to obtain the best result from treatment of
massive trauma.
Minor complications are not uncommon and can
usually be managed with minor revisions. Major complications from tissue loss or malposition are best
prevented but major reconstructive procedures with
osteotomies and bone grafting can provide satisfactory
final results.

1170

Section V: Trauma

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1. DeLacure MD. Physiology of bone healing and bone grafts.
Otolaryngol Clin Ntmh Am 1994;27:859-874.
2. Manson PN. Facial bone healing and bone grafts: a review of
clinical physiology. Clin Plast Surx 1994;21:331-348.
3. Phillips JH. Rabin BA. Bone healing. In: Yaremchuk MJ, Gruss JS,
Manson PN, eds. RiKid fixation of the cnmiomtuillofucial skeleton.
Boston. MA: Butterworth-Heinemann. 1992.
4. Alpert B. Complications in mandibular fracture treatment. Probl
Pfast Reconstr Surg 1991; 1:253-289.
5. Kendrick RW. Management of gunshot wounds and other urban
war injuries. Oral Maxr11ofac Surg Clin North Am 1990;2:55-68.
6. David DJ, Simpson DA.. eds. Craniomaxt11ofacial trauma. New
York Churchill Livingstone, 1995.
7. Shao XH. f\1 QH, Liu Y. The use of self-reinforced P (L/D)lA bioabsotbable internal fixation system in oral maxillofacial fractures.
Shanghai Kou Qiang YiJWefShanghai I Stomatol2004;13(1 ):78- 80.
8. Gutwald R. SchOn R. Gellrich NC, et al. Bioresotbable implants
in maxillo-facial osteosynthesis: experimental and clinical aperience.lnjury 2002;33(2):SB-4-16.
9. Prein J, Kellman RM. Rigid internal fixation of mandibular fractures: basics of AD technique. Otolaryngol Clin NorthAm 1987;20:
441-456.
10. Valentino J, Lvy FE, Marentette U. Intraoral monocortical miniplating of mandible fractures. Arch Ot:olaryngol Head Neclt Surx
1994;U0:605-612.
11. Haug RH. Effect of screw number on reconstruction plating. Oral
Surg Oral Med Oral Pathol1993;75:664-668.
12. Kellman RM. Recent advances in facial plating techniques. Facial
Pfast Surg Clin North Am 1995;3:227-239.
13. Park CH. Kim HS, Lee JH, et al. Resotbable skeletal fixation 5}'3tems for treating maxillofacial bone fractures. Arm Otolaryngol
Head Neclt Surx 2011; 13 7(2): 125-129.
14. Kellman RM, Marentette U. Atlas of craniomaxr1lofacial fixation.
NewYorl<: Raven Press, 1995.
15. Mathog RH. Atlas of craniofacial trauma. Philadelphia, PA: WB
Saunders, 1992.
16. Stanley RB. Current approaches to LeFort and zygomatic fractures. Facial Plast Surg Clin North Am 1995;3:97-105.
17. Gellrich N-C, Schramm A. Hammer B, et al. Computer-assisted
secondary reconstruction of unilateral posttraumatic otbital
deformity. Plast ReconstrSurx2002;no:1417-1429.
18. Bell RB. Computer planning and intraoperative navigation in
crania-maxillofacial surgery. Oral Maxr1lofac Surg Clin North Am
2010;22(1):135-156.
19. YuH. ShenG, Wang X. ZhangS. Navigation-guided reduction and
otbital floor reoonstruction in the treatment ofzygomatic-otbitalmaxillaiY complex fractures. I Oral Maxr11ofac Surg 2010;68(1):
28-34.
20. Grobe A. Weber C, Schmelzle R. et al. The use of navigation
(BrainiAB Vector vision (2)) and intraoperative 3D imaging
sy3tem (Siemens Arcadia Orbic 3D) in the treatment of gunshot wounds of the maxillofacial region. Oral Mtuillofuc Surg
2009; 13(3): 153-158.
21. Schramm A. Suarez..Cunqueiro MM. Rucker M, et al. Computerassisted therapy in otbital and mid-facial reconstructions. Int
J Med Robot2009;5(2):111-124.
22. Li wz. Zhang MC, Li SP, et al. Application of computer-aided
three-dimensional skull model with rapid prototyping technique
in n:pair of zygomatiaH>rbito-maxillaiY complex fracture. Int
J Med Robot2009;5(2):158-163.
23. Mathur I<K. Tatum SA. Kellman RM. Catbonated apatite and
Hydroxyapatite in craniofacial reconstruction. Arch Facial Plast
Surg 2003;5:379-383.
24. Shumrick KA.. Kersten RC, Kulwin DR. et al. Extended access/
internal approaches for the management of facial trauma. An;h
Otolaryngol Head Neclt Surg 1992;118:1105-1112.
25. Dierks BJ. Transoral approach to fractures of the mandible.
Laryngoscope 1987;97:4-6.

26. Kellman RM. Endoscopic assisted n:pair of subcondylarfractures

of the mandible: an evolving technique. An;h Facial Plast Surg
2003;5:244-250.
27. Klotch ow, Lundy LB. Condylar neck fractures of the mandible.
Otolaryngol Clin North Am 1991;24:181-194.
28. Worsaae N, Thorn JJ, Surgical versus nonsurgical treatment of
unilateral dislocated low subcondylar fractures: a clinical study
of 52 cases. J Oral Mtuillofuc Surg 1994;52:353-360.
29. Haug RH, Assael lA. Outcomes of open versus closed treatment of mandibular subcondylar fractures. ] Oral Mtuillofac Surg
2001;59:370-375.
30. Garcia GH, Goldberg RA, Shotr N. The transcaruncular
approach in repair of otbital fractures: a retrospective study.
J Craniomaxr11ofac 'ltauma 1998;4:7-12.
31. Thoren H, Numminen L, Snail J, et al. Occurrence and types of
dental injuries among patients with maxillofacial fractures. Int
J Oral Mtuillofuc Surg 2010;39(8 ):774-778.
32. CholeRA, Yee J, Antibiotic prophylaxis for facial fractures: a prospective. randomized clinical trial. An;h Ot:olal}'rlgol Head Neck
Surg 1987;113:1055-1057.
33. Gupta IX, Levin PS. Ophthalmic consequences of otbital trauma.
Oral Maxr11ofac Surx Clin North Am 1993;5:443-455.
34. Manson PN. Dimensional analysis of the facial skeleton: avoiding complications in the management of facial fractures by
improved o~ization of treatment based on cr scans. Prob Plast
Reconstr Surg 1991;1:213-237.
35. Kim JJ, Huoh K. Maxillofacial (midface) fractures. Neuroimaging
Clin N Am 2010;20(4):581-596.
36. Wilson IF, I.okeh A. Benjamin CI, et al. Prospective comparison
of panoramic tomography (zonography) and helical romputed
tomography in the diagnosis and operative management of mandibular fractures. Plrut Reconstr Surg 2001;107:1369-1375.
37. Ladrach K. Annino DJ, Raveh J, et al. Advanced approaches to
crania-orbital injuries. Facial Plast Surg Clin North Am 1995;3:
107-130.
38. Kellman RM. Use of the subcranial approach in maxillofacial
trauma. Facial Plast Clin North Am 1998;6:501-510.
39. Anderson RL. Panje WR. Gross CE. Optic nerve blindness
following blunt forehead trauma. Ophthalmology 1982;89:
lA45-IA55.
40. Joseph MP, I..essell S, Rizzo J, et al. Emacranial optic nerve
derompression for traumatic aptic neuropathy. Arm Ophthalmol
1990;108:1091-1093.
41. Wenig BL. Man~ment of panfacial fractures. Otolaryngol Clin
North Am 1991;24:93-101.
42. Derdyn C, Persing JA.. Broaddus EC, et al. Craniofacial trauma: an
assessment of risk related to timing of surgery. Plast Reconstr Surg
1990;86:238-245.
43. Haug RH, Buchbinder D. Incisions for access to craniomallillofadal
fractures. Atlas Oral MtuiDofac Surg OinNorthAm 1993;1:1-29.
44. Guven E, Ugurlu AM, Kuvat SV, et al. Minimally invasive
approaches in severe panfacial fractures. Ulus Thlvma Acil Cerrahi
Derg 2010; 16( 6) :541-545.
45. Pedroletti F. Johnson BS, McCain JP, Endoscopic techniques in
oral and maxillofacial surgery. Oral Maxr11ofac Surg Clin North Am
2010;22(1):169-182.
46. Schubert w, Jenabzadeh K Endoscopic approach to maxillofacial
trauma. J Craniofac Surg 2009;20(1):154-156.
47. Mueller R. Endoscopic treatment of facial fractures. Facial Plast
Surg 2008;24(1 ):78-91.
48. Gruss JS, Van Wyck I.. Phillips JH, et al. The importance of the
zygomatic arch in complex midfacial fracture repair and correction of posttraumatic otbitozygomatic deformities. Plast Reconstr
swx 1990;85:878-890.
49. Wagner JD, Baack B, Brown GA. et al. Rapid 3-Dimentional prototyping for surgical n:pair of maxillof.r.ci.al fractures: a technical
note. J Oral Maxr11ofac Surg 2004;62:898-901.
50. Brandt MT, Haug RH. The use of a polyurethane skull replica as
a template for contouring titanium mesh. J Oral Mtuillofuc Surg
2002;60:337-338.

John F. Hoffmann

There have been three principal advances that have revolutionized the management of craniofacial trauma over the
last several decades. These are advanced imaging, sophisticated internal fixation technology, and aesthetic surgical approaches. Modem computed tomography scanning
allows for visualization of the craniofacial skeleton in
multiple perspectives as well as in three dimensions. This
enables the clinician to precisely identify fracture patterns
and anatomy. Sophisticated internal fixation plating systems have evolved to allow the surgeon to precisely and
rigidly fixate craniofacial fractures so that normal anatomy
can be restored and stabilized against the forces of mastication. Contemporary surgical approaches to the craniofacial skeleton have also advanced to allow one to expose
facial fractures in a way that provides optimal visualization
for fracture reduction and placement of fixation hardware
while minimizing soft tissue damage and scarring. In some
instances, surgical incisions for aesthetic facial surgety have
been adapted to the exposure of the craniofacial skeleton.
An example would be the lateral upper lid crease incision
that has been adapted from blepharoplasty procedures.
The surgeon should be familiar with the relaxed skin tension lines of the face and neck and place elective incisions
within these whenever possible, thereby minimizing the
visibility of the final scar. Meticulous and gentle soft tissue handling techniques are paramount to obtaining rapid
healing with minimal scarring. Similarly, the use of electrocautery should be judicious especially in areas of thin soft
tissues and around hair follicles. Intimate knowledge of the
location and couBe of critical nerves-such as the facial
and trigeminal neiVes-is essential. This chapter discusses
the various options for exposing the craniofacial skeleton from the frontal sinus to the mandible. Endoscopic
approaches have gained some popularity in the management of orbital, frontal sinus, zygomatic arch, and mandibular condyle fractures. These techniques are beyond the
scope of this chapter, however.

UPPER FACIAL SKELETON

AND FRONTAL SINUS
The workhoBe approach for the upper facial skeleton is
the hemicoronal or full coronal incision. This classic surgical approach enables the surgeon to expose the upper frontal and parietal skull all the way inferiorly to the superior
orbital rims, orbital roof, and nasoethmoid region as well
as the entire zygomatic arches (1). The coronal approach
also can be employed in those instances in which cranial
bone grafts will need to be harvested. In cases of unilateral fracture, a hemicoronal approach extending from the
midline down to the ipsilateral pinna may be considered.
It must be remembered, however, that a hemicoronal flap
will have more limited inferior exposure compared to a full
coronal flap due to the reduced inferior rotation of the flap.
Coronal flaps typically have robust blood supplies and can
be designed to include pericranial tissues as well. In the
instances where the posterior table of the frontal sinus is
fractured and the risk of cerebrospinal fluid (CSF) leakage
is high. the surgeon should be very careful to preseiVe the
vascularity of the pericranial tissue as a pericranial flap may
be very helpful in these cases to repair dural injuries.
The coronal incision has classically been described as a
straight-line incision extending from just above the pinna,
couBing several centimeters behind the anterior hairline
across to the contralateral side as needed. Typically, the
incision is made several centimeters behind the hairline
(Fig. 79.1). In men, one may need to locate the incision
more posteriorly to accommodate male pattern baldness.
One disadvantage of the straight-line incision, however,
is that it may be more visible. This is particularly true
when the hair is wet as it may part away from the incision making it very visible (Fig. 79.2). Alternatives to the
straight-line incision include a curvilinear incision or a
"sawtooth" design (Fig. 79.3) {2). These modifications are
intended to help camouflage the parietal portion of the

1171

1172

Section V: Trauma

Figure 79.1 Typical CJOronal incision location for women and men
with no significant baldness. In men
with baldness, Ute incision is moved
posteriorly as needed. (From Ellis E,
Zide MF.. Surgical approaches to the
facial skeleton, 2nd ed. Philadelphia,
PA: Lippincott Williams & Wilkins,
2006, with permission.)

coronal incision. As these incisions are more irregul~ wet

hair will be far less likely to part away from the incision in
a straight line and thereby make it less visible. A sawtooth
design, howeva;. may predispose the poinu of the sawtooth to some alopecia, thereby making the incision more
visible. Regardless of which incision design is selected,

the incision should be made parallel to the hair follicles,

thereby minimizing the risk of injuring the follicles. It is
also advisable to minimize the use of electrocautery along
the incision line as this also may widen the area of alopecia and potentially lead to more hypertrophic scarring.
Raney clips or compression sutures may be used along the

6
Figure 79.2 Coronal Incision scarring. A:. Highly visible strait scar, especially noticeable whcm the
hair Is wvt and falls away from the scar. 1: Intraoperative design of a curvilinear CJOronal lndslon.

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

c
Figure 79.2 (Continued) C: Postoperative appearana~ of a curvilinear lndslon, wtlich Is hidden since hair tends to not part In a
straight line.

edges of the incision to aid hemostasis, but these also may

lead to more alopecia due to pressure injwy of the follicles.
The lateral extent of the incision is normally at the apex of
the ear. In cases where exposure of the zygomatic arch is
anticipated, the incision may be extended inferiorly in a
preauricular crease down to the tragwl. Centrally, the flap
may be elevated in a subgaleal or in a subperiosteal plane.
If the flap is raised initially in the subgaleal plane, then a
transition will need to be made through the pericranium

Figure 79.3 Sawtooth design alternative for a coronallndslon.

This may lead to alopeda at the tips of the triangular Incision
points.

1173

above the fracture site itself. The surgeon must anticipate

the potential need for a pericranial flap early in the flap
design and plan accordingly. A pericranial flap may be
devdoped separately or dissected off of the galea once the
flap has been raised (Fig. 79.4). In the parietal and temporal aspects of the flap, the typical dissection plane is in
the loose areolar tissue beneath the temporoparietal fas.
cia and just superficial to the deep temporalis muscle fas.
da. Blunt dissection over the temporalis fascia allows for
rapid inferior eleation of the flap in a relatively bloodless
plane. One must. however, sharply release the fascia along
the anterior temporal line as it is firmly affixed to the periosteum here. As will be discussed below, the lateral blunt
dissection must be stopped several centimeters above the
zygomatic arch in order to avoid injury to the frontotemporal branches of the facial nerve.
As the flap eleation proceeds inferiorly, the SUip!On
should carefully identify and prese~Ve the supraorbital
neurovasailar bundles. The suprao:rbital structures may
emerge from the orbit via a notch in the superior orbital
rim or from a complete bony foramen usually at the junction of the medial and central thin:1s of the orbital rim (3).
In order to fully visualize the superior orbital rim and to
extend dissection into the nasoethmoid region or the orbital
root the supraorbital structures must be mobilized. If the
flap has been raised in a subgaleal plane, then a transition
tluough the pericranium is made several centimeters above
the supraorbital rims. If the supraorbital bundles are within
a notch, then the careful subperiosteal eleation will release
them. 1 howeva;. these structures exit through a foramen,
then an osteotomy may be necessary to fully mobilize them
(F'tg. 79.5). Once the supraorbital structures are released, the
dissection can proceed inferiorly to expose the nasal root.
the medial canthal region, the nasal ethmoid complex. and
the orbital roof. The swgeon should be careful during e:xp~
sure of the medial orbital wall and nasoethmoid region to
not detach. the medial canthal tendon from the bone as this
would lead to soft tissue telecanthus, which can be quite
diffiwlt to com!Cl The coronal incisions will also provide
aaillent exposure of the lateral orbital rim and the front~
zygomatic junction. a site frequently involved in facial fractures. Again one should be cautious to not detach the lateral
canthal tendon during subperiosteal dissection as well to
prevent postoperative malposition of the lateral canthus.
The coronal approach also provides an ideal swgical exposure of the zygomatic arches (4 ). Exposure of the
an::hes may be necessary either in severely comminuted
and displaced zygomaticomaxillary-orbital fractures or
in LeFort 1D fractures. With exposure of the an::hes, how~ the surgeon must alter his dissection plane in order
to avoid injw:y to the frontotemporal branches of the facial
nerve. Below the level of the zygomatic arch, the facial
nem! travels beneath the superficial musculoaponeurotic
system (SMAS) layer. At the level of the zygomatic arch,
however, the fascial planes coalesce and the facial nerve
branches pass aver the zygomatic arch where they are quite

1174

Section V: Trauma

wlnerable to swgical injury. Once above the zygomatic

arch. the facial nerve lies within the temporoparietal fascia on its way to the corrugator and frontalis muscles. In
older to avoid injwy to the facial nerve u it passes aver the
zygomatic an:h. the surgical dissection plane must change.
If dissection were to continue along the surface of the deep
temporalis muscle f.tscia, then the facial nerve would be
damaged at the level of the arch. To avoid thi!, the dissection plane should change several centimeters above the
zygomatic arch (Fig. 79.6). An incision should be made
through the superficial layer of the deep temporalis fascia, and then dissection should continue inferiorly on the
undersurface of this fascia. this space contains the temporal
fat pad, and one should minimize disruption of the fat pad

Figure 79.4 Periaanlal Rap elevated In conjunction

with coronal Incision. This may bel needed to help seal
CSF leakage In severe frontal or nasoorbltal fractures.
(From Ellis E, ZJde MF.. Surgical approaches to the facial
skeleton, 2nd ed. Philadelphia, PA: Upplncott Williams &
Wilkins, 2006, with pennlsslon.)

during dissection to help minimize postoperative atrophy.

Attophy of this fat pad can lead to hollowing within the
temporal fossa, which is aesthetically displeasing and is diffiallt to correct The zygomatic arch should be approached
along its superior border at which point the periosteum i!
incised and elevated. the facial nerve branches will then be
contained within the soft tissues of the flap. 1he arch can
then be exposed along its entire length from its origin at
the temporal bone to its attachment to the malar eminence
(Fig. 79.7). At the conclusion of the procedure. it is critical
to resuspend the soft tissues to avoid ptosis of the malar
tissues (5). This is typically done by suturing the mobilized
fascia back to the temporalis f.tscia, taking care while placing the sutures to not injure the facial nerve.

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

c
Fig... 79.5 Coronal flap elq)OSure frontal skeleton. A:. Mobilization of the supraorbital neurovascular pedides with osteotomies. B: lmraoperative photo of CJOronal flap with mobilized supraorbital
stn~ctures seen bilaterally. C: lmraoperative photo of fixation hardware in plaat for repair of comminuted frontal sinus fracture. (Part A from Ellis E, Zide MF. Surgical approaches to the facial skeleton,
2nd eel. Philadelphia, PA: Lippincott Williams 8r. Wilkins, 2006, with permission.)

1175

1176

Section V: Trauma

Temporalis
Fascia -~,........

ntr+--~-

VII

Temporal Portion of
Buccal Fat Pad

Figure 79.6 Exposure and dissection planes In temporal region and zygomatic arch. A:. Tissue~
planes and location of frontal branch of facial nerve over the zygomatic arch. 1: OlsSCICtion plane~
over zygomatic arch to avoid InJury to the facial nerve branches. Abow the arch the plane of dlssec>
tlon passes through the deep temporal fascia Into the temporal fat pad. The periosteum In Incised
along the supcarior border of the arch and Is elevatcad deep to the facial nerVe~. (From Ellis E, Zlde MF..
Surgical BfJP"OBc:hes to the fsclsl skeleton, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2006, with permission.)

A suction drain may or may not be required and can

be used at the surgeon's discretion. The scalp incision
is then carefully dosed in a layered fashion. All tension
on the wound should be borne by sutures placed within
the galeal layer, and cutaneous closure should only be
done to realign the epithelium correctly. Excessive skin
closure tension will possibly lead to increased scarring
and alopecia. Complications of the coronal approach
include bleeding or hematoma, temporary or permanent
numbness of the forehead tissues, injwy to the frontal
branches of the facial nerve. and excessive scarring or

alopecia. Patient should be counseled that some degree

of numbness is inevitable posterior to the incision.
Another alternative for exposure of fracwres of the
upper facial skeleton exists when there is a large laceration. This most commonly oc:cw:s in fractures of the frontal sinus as direct blows to this region will often cause
lacerations. Another common location of lacerations is
along the lateral brow, and occasionally these can be used
to expose the frontozygomatic area and the lateral orbital
wall. One should be cautioned, howeve:t to avoid significantly lengthening a laceration to obtain appropriate

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

1177

MIDFACIAL SKELETON
Orbit

FiguN 79.7 lmraopemve exposure and plating of zygomatic

arch in a LeFort Ill fracture. Temporalis muscle is retracted to the
right of the picture.

exposure of fractures. This could easily lead to umightly

scarring or possible nerve injury. In general, one should
avoid the historical eyebrow or ...gullwing" incision. This
routinely leads to unsightly scarring and a deformity of
the eyebrows (Fig. 79.8). There is significant propemity for
chronic edema in this dependent :flap as well as extensive
numbness of the forehead. For these reasons, a coronal
flap should be employed as it provides unparalleled access
and a far more pleasing aesthetic result. 1hU is true even in
patients with baldness.

Figure 79.8 "Gullwlng" brow Incision. Note chronic edema of

flap above the Incision and the highly visible scar.

The lateral orbital wall and &ontozygomatic area can be

easily approached via upper eye lid crease incisions. In
essence, this type of incision is a limited lateral blepharoplasty incision. Historically, incisions adjacent to or
within the lateral brow were advocated. Howeva;. these
incisions frequently leave unsightly scars or may cause
permanent hair loss in the eyebrow and do not offer
any exposure advantage over the lid crease incisions
(Fig. 79.9). Instead. placing the incision within the lateral upper eyelid crease is far more preferable aesthetically and also provides improved exposure of the lateral
orbital rim and medial aspect of the lateral orbital
wall. The technique is very straightforward (Fig. 79.10).
The lateral aspect of the lid crease is marked prior to
the injection of local anesthetic. The incision is made
through the skin and the underlying orbicularis :fibers
are bluntly separated. The periosteum of the lateral rim
is incised and elevated as needed for fracture exposure
and implant placement. It is frequently beneficial to
extend the subperiosteal exposure posteriorly along the
lateral orbital wall. This allows the surgeon to visualize
the displaced fractures and provides another perspective
to evaluate accurate anatomic reduction of fracture segments. Following fracture repair, the periosteum is closed
and the incision is closed in a layered fashion. It is not
typically necessary to drain this incision. Although one
may see some temporary orbicularis weakness postoperatively, permanent lagophthalmos should be very rare.
Healing is usually rapid with an excellent aesthetic result
(Fig. 79.100).

Figure 79.9 !Aft lateral brow Incision. This scar an be very

visible and cause permanent loss of eytabrow hairs and has more
limited exposure of the !literal orbit and should bQ avoided.

1178

Section V: Trauma

Figure 79.10 Lateral lid aease (upper blepharoplasty} approach. A:. Incision is placed in natural
supratarsallid crease as shown and extended laterally within the aease as needed. 1: Periosteum of
lateral wall is incised and elewted to expose bene above and below the fracture to allow reduction
and fixation hardware placement. The orbital aspect of the lateral wall should be exposed and
villualized fer aocurate &acture reduction. C: Intraoperative photo showing hardware placement.
D: Postoperative photo following ORIF of right malar <XImplex fracture with inconspio.acull incision
healing. (Part B From Ellis E, Zide MF. Surgical approaches to the fadal skeleton, 2nd ed. Philadelphia,
PA: Lippin<XItt Williams 8r. Wilkins, 2006, with permill!lion.}

Inferior Orbital Rim, Floor, and Medial Wall

The inferior orbital rim, orbital floor, and medial orbital
wall are most commonly approached through. the various
lower eyelid incisions. These incisions may either be ttanscutaneous or transconjunctival (Fig. 79.11 ). Both of these
approaches have been long advocated in the literature, and
when carefully designed and executed, both approaches will
yield excellent results (6). nansconjunctival approaches
have several potential advantages, however (7). Obvi.owly,
there is no visible scar unless a short lateral canthotom:y
incision is incorporated. A transconjunctival approach
lends itself very well to extended medial exposure for fractures involving the medial orbital wall. In addition. ttansconjunctival approaches are completely posterior to the

o:rbiallaris muscle of the lower eyelid and therefore preseiVe an important structural support of the lower lid. As
a result. postoperative lower lid malposition or ectropion
may be less common with a transconjunctival approach
(8,9). Furthermore, a transconjunctival approach can be
done in some OllJes without any division of the lateral
canthal structures and thus weaken lower lid support
even less.
Transconjunc:tival Lower Ud Approaches
1he lower eyelid transconjunctival approach is begun
with an incision placed in the inferior fornix. A corneal
shield om be employed if desired but may impede exposure somewhat If a shield is used for a long case, such as
a complex nasoethmoid or LeFort fracture, one should

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

1179

Figure 79.11 Transcutaneous and transconJunctlvalapproac:hes to the orbital floor. A:. Cross-section
of eyelids demonstrating surgical planes for 1ranscutaneous (subdllary or lid crease) approach.
B: Cross-section of eyelids demonstrating transconJunctlval approach. Following the lndslon In the!
Inferior fornix. the dissection can proceed either anterior or posterior to the orbital septum (see Text
and Figure 79.13).

remove the shield periodically and reapply ocular lubricant to reduce the risk of corneal compromise or abrasion.
Initially, the lower lid is retracted gently, and the incision
is typically made several millimeters below the tarsal plate.
Limited o:rbital floor fract:ures may be repaired with this
incision alone without any lateral canthotomy incision.
One should uy and avoid a lateral canthotom:y if possible
as these approadtes heal with the lowest incidence of lid
malposition (7). If. howev~ the orbital floor fracture is
lru:ge, the lid has little laxity, or if one anticipates the need
to explore the medial o:rbit, a lateral canthotomy and cantholysis may be necessary (Fig. 79.14). The lateral canthotom:y incision is made directly through the lateral canthus
and typically extends only a few millimeters. E!:tendin.g
the cutaneous incision beyond this will not enhance exposure and will make the incision more visible. The lateral
canthal tendon is then divided with a cantholysis, which
is typically performed with small tenotomy scissors angled
obliquely downward under the conjWictiva. The canthal
tendon :fibers are fully divided so that full mobilization of
the lower lid is obtained The conjWlctival incision is then
extended along the inferior fornix a few millimeters below
the inferior border of the tarsus. A flap of conjWictiva and
lower lid rettactoiS is created and retracted superiorly with
a traction suture (Fig. 79.128). This provides coverage of
the cornea and often eliminates the need for a corneal
protector. Tension on this :Oap will also provide countertraction. which will aid the inferior dissection toward the

rim. At this point,. there are two options for surgical dissection: preseptal or post (retro) septal (F"tg. 79.13). Preseptal
dissection is typically done with blunt insttuments in the
loose areolar ti8sue between the orbicularis muscle and
the o:rbital septum inferiorly until the infraorbital rim ia
encountered. An advantage of this approadt is that the
orbital fat is largely contained by the septum and therefore
does not obsOJre visualization. A potential disadwntage ia
that scar contracture could ocrur along the orbital septum
leading to some postoperative displacement or malposition
of the lower lid. This may result in inferior displacement
of the lower lid leading to increased scleral show or perhaps some entropion ( 10,11). Retroseptal dissection is also
blunt but is behind the orbital septum and traverses the
o:rbital fat. A principal disadwntage of this approadt is that
visualization may be more difficult as the orbital fat will
protrude into the surgeon's view, and there is a somewhat
greater potential for injury to the inferior oblique muscle
as it is adjacent to the plane of dissection. Advocates of this
approach. howeva;. feel that the risk of lower lid malposition is Lugely eliminated as there ia no contracture along
the o:rbital septum. In either approach. the orbital rim ia
quickly and widely exposed (Fig. 79.14). The periosteum
of the rim is then incised, and wide subperiosteal diasection is pe:rformed as dictated by the fracture. It is essential
that the dissection along the o:rbital floor be complete and
be carried out to fully expose the intact bony shelves along
the lateral orbital fl.oo~;. medial orbital floo~;. and especially

1180

Section V: Trauma

F
Figure 79.12 Transconjunctiwl approach. A:. Incision is made in inferior fornix several millimeters
below the inferior border of U:te tarsus. B: A flap of cxmjunctiva and lower lid retractors is developed
and retracted superiorly with a suture. This provides corneal protection and facilitates U:te dissection.
A corneal shield can be employed if desired. C: lntraoperUve photo with &llpOSI.Ire of infraorbital
rim and orbital floor fractures. D: Cros9-sec:tion of orbit demonstrating elevation of orbital floor peri
osteum. E: lntraopermive photo demon~ng fixaUon hardware in plaat. F: Postoperative photo
following repair of right zygommicom!VIillary-orbital fractures demonstrating healing of lower lid in
excellent poshion. No canU:totomy was perfonned. (Part D from Ellis E. Zide MF.. Surgical approaches
to the fadalsl<klton, 2nd ed. Philadelphia, PA: Upplncott Williams & Wilkins, 2006, with permission.)

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

1181

Figure 79.13 Sagittal view of orbit demonstrating pre.septal versus retroseptal planCIS of dissection. (From Ellis E, Zlde MF.. Surgical approaches to the facial snteton, 2nd ed. Philadelphia, PA:
Upplncott Williams & Wilkins, 2006 with permission.)
back to the posterior orbital bony shelf. Care is taken during floor dissection to bluntly identify the infrao:rbital
nerve and separate it from the orbital soft tissues. Repair
of the &acture is then performed using the implant or graft
preferred by the swgeon. At the conclusion of the repail;.
it is important to repair the periosteum along the in&aorbital rim. This is particularly true if there has been wide
elevation of the periostewn off of the face of the maxilla
or malar eminence as in a malar complex. or LeFort &acture
repair. In those cases, closure of the periosteum will help
prevent inferior displacement or ptosis of the midface soft
ti.uues. It is not necessaJY to close the conjunctiva although

a few sutures to realign the edges may be helpful. There is

some wisdom to not closing the conjunctiva tightly as this
will allow blood and serous fluid to escape from the orbit
postoperati:vdy: If a canthotomy and cantholysis have been
performed, then the lateral canthal tendon segments are
carefully reapproximated, and precise closure of the lateral
canthus is essential. Failure to close the lateral canthus precisely could lead to rounding or webbing in this area.
A medial extension of the transconjun.ctival approach
provides an opportunity to fully expose the medial orbital
wall as well. This is done with an atmsion 1h:rough the
c:arunallar area (Fig. 79.15) (12,13). The caruncle is thesoft

1182

Section V: Trauma

Figwe 79.14 Technique for lateral canthotomy and cantholysis. A:.

Lateral canthotomy incision. This is typiallly 3 to 5 mm lang. B: Inferior
cantholy9is. The canthal tendon fibers are divided either through Ute
CXII'ljunc:tiva or submuc:osally but never through Ute skin. The tendon
fibers can usually be palpated with Ute scissor tip as a '"bowstring.'"
C: Artin's depiction of cantholy9is. D: Complete lid mobnimian is
apparent after the tendon fibers are divided. E: Postoperative view
following repair of left orbital floor fracture with c:anthotomy/c:antholysls and 11'8nsc:onjunc:tival approach. (Part C from Ellis E, Zlde MF..
Surgical spprosches to the fsdal slceleton, 2nd ed. Philadelphia, PA:
Upplnc:ott Williams & Willdns, 2006, with permission.)

tissue collection in the conjunctiva, which lies posterior and

lateml to the medial canthus and just anterior to the semiIWlar fold of the conjWictiva. Deep to the auuncle are the
attachments of the medial omital septum and Homer mu
de and portions of the medial canthal tendon. the common
canaliOJius is immediately medial to the caruncle as wdl.
The carunOJiar approach can be performed as an isolated
incision to gain access to the medial omital sttucwres as in

an isolated medial wall fracture. More often, it is combined

with the lower lid transconjunctival approach to provide
wide access for the entire inferior and medial orbital structures. Typically, the lower lid portion is executed :fu:st and the
dissection is then extended medially. A lateral canthotomy
and cantholysis, as discussed above, may facilitate better
exposure in this instance Orbital retractors are employed to
retract the globe laterally and the medial canthus medially.

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

1183

Figure79.15 Transcaruncular approach.A:Thelndslon Is made

through the medial conjunctiva immediately posterior to theca!'unde. 1: Periosteum Is lndsed along the posterior lacrimal crest.
C: Axial section demonstrating plane of dissection to expose
the medial orbit via the caruncular approach. (From Ellis E,
Zlde MF. Surgical approaches to the facial slcelmon, 2nd ed.
Philadelphia, PA: Upplnc:ott Williams & Wilkins, 2006, with pe~'>
mission.)

1he incision is made between the caruncle and the semilunar fold of the conjunc::tiva Dissection with a small tenotomy scissor or periosteal elevator atends posteriorly Wltil
the posterior laaimal aest is palpated. the periosteum is
incised along or just posterior to the posterior laaimal ~st.
and the exposure is atended posteriorly and superiorly as
indicated. It is essential to only dissect posterior to the lacrimal fossa in oroer to avoid damaging the laaimal sac and
canaliaili. this tmnscaruncular approach will allow visualization from the laaimal fossa up to the frontoethmoid
suture and the ethmoid arteries and even the medial orbital
roof. When more extensive superior exposure is required,
the ethmoid arteries can be aut.erized or ligated and divided
while remaining cognizant of the neaxby optic nf!IVf! loalion. Once the swgical repair is complete. the conjunctiva is
closed near the jWlCtion of the wall and Boor boun.daJ:y as
this will help to prevent webbing between the medial wall
and lower lid conjunctiva the patient may have some chemosis and edema postoperatively, but the healing is rapid
and the final result is aesthetically excellent and far superior
to the transcutaneous medial wall, "'Lynch. incisiom that
often heal with unsightly scarring that is hard to amoufiage

(Fig. 79.16). the Lynch incision is simple to execute. and the

dissection is direct to the medial o!bital wall. However, the
inferior dissection is limited by the laaimal structures, and
there is more risk of detaching the medial canthal tendon.
More importantly though is the fact that the scar is potentially quite visible and somewhat prone to webbing as it
heals and contractlJ. If one insists on using a transcutaneous
medial o:rbital incision. a Z-plasty should be incorporated
into the design of the incision to minimize webbing of the
scar as it heals, and this will help to camoufiage the final
scar. Ovmill.. the canmcular approach through the conjunctiva is far superior and it is strongly recommended.
In general, transconjunctival approaches heal predictably well ( 6,8,9,11 ). Prolonged chemosis may occasionally
occur. Eyelid malpositions are uncommon and may result
either in increased scleral show from vertical contracture or
perhaps entropion if there is contracture of the posterior
lamellar tissues (10). Most of these will improve with time
and massage but occasionally will require corrective surger:y
with scar release and perhaps mucosal grafting to the posterior lamella. If there is significant lateral canthal webbing
or scarring, then secondru:y canthoplasty may be needed.

1184

Section V: Trauma

Figure 79.16 A; Postoperative vie~w following repair of large

fracture left me~dlal orbital wall via caruncular approach. B: Axial
CIT scan of patle~nt shown In (A). C: Postoperative view of a I'I'Kidlal
orbital fracture repaired through a Lynch Incision. Note the highly
visible scar as well as a visible subdllary Incision on the! left.

c
Transcutaneous Lower Lid Approaches
There are se"Vmll options for rutaneous incisions in the lower
lid (Fig. 79.17).1he subdliaJ:y incision is perhaps the most
commonly employed and is typically placed 2 to 3 mL below
the eyelashes. A good alternative is to place the incision
within a nab.lrallalm' lid crease (subtarsal), which is below
the subciliary line (8,14). Placing the incision directly over
the infi:aOibital rim should usually be avoided as this location is more prone to visible scarring and may lead to prolonged lower lid edema above the incision and sits in thicker

(F~g. 79.18). With tran.srutan.eous approaches,

corneal protection is prorided by placing a temporary tarsorrhaphy suture from the lower lid up to the upper lid, taking
care that the suture does not peneaate the conjunctiva (Pig.
79.20A). Ifone chooses the subdliaJ:y approach, the incision
is made through the skin only a few millimeters below the
lashes and typically stair-stepped presenring a cuff' of orbicularis muscle along the talsus as this helps to support the
lower lid position while healing. Below the tarsus, the orbicularis is penetrated and the skin-muscle flap is then bluntly
raised off of the underlying orbital septum down to the
infi:ao:rbital rim (Fig. 79.19). If a lower lid crease (subta!sal)
is chosen for the incision. then a skin-muscle flap iJ immediately devdoped as the crease is typically below the level of

cheek skin

Figure 79.17 Transcutai'IQous lower eye~lld Incision. From supe~rior

Figure 79.18 Postoperative appearanoa of an Inferior rim lnd

slon. Note the visibility of the scar, the chronic Clde~ma, and the

to Inferior: subdllary, lid creaSCI, and Infraorbital rim.

lower lid malposition.

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

1185

Figure 79.19 Sagittal view of plane of dissection with transc:utaneous approach. (From Ellis E,
Zide MF. Surgical approache$ to the facial skeleton, 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006, with permission.)

the tarsus. Dissection is again between the o:tbicularis and

orbital septum. The inframbital rim is exposed and the periosteum is incised, and dissection continues along the floor
as needed far fracwre repair (Fig. 79.20). A1 the conclusion
of the repaiJ; it is important to close the periosteum along
the rim to help suspend the elevated premaxillaJY soft tissua
and to provide soft tissue covemge over the fixation hardware. During closure of the skin-muscle flap, it is aitical
that the :flap be resuspended to the periosteum of the lateml mbital rim near the lateral canthWI. This is important
because the skin-muscle :flap weakens the support of the
lower lid by dividing and partially denervating the orbirularis muscle, which is a critical support of the IO'M7 lid The
SWipension suture, t}'pically a 5-0 slowly resorbing suture
materiaL is placed from the o:tbicularis of the :flap to the

lateral o:tbital rim periosteum. The suspension suture should

be tightened so that the skin edges are brought together with
no tension along the incision line. If the periosteum ia lacking or has been elevated during fracwre repait then one can
drill a small hole in the bone of the lateral rim and pass the
suture through that. Flderly patients frequently have some
preexisting laxity of the lower lid, and in these patients, some
tightening of the lateral canthal structures at the time of
wound closure will help prevent lid malposition.
A major criticism of the transcutaneous approachparticularly the subcilial:y approach-is that it ia potentially
more prone to cause malposition of the lower lid, particularly
edropion (Fig. 79.21) (6,8,9). This ia thought to be due to
contmdUre along the orbital septum or anterior lamella (i.e.,
skin and orbicularis) combined with weakening of the lower

1186

Section V: Trauma

Figure 79.20 Transcutaneous exposure of the orbital floor.

A:. Subciliary incision has been made and skin-musde flap has been
developed. A temporary tarsorrhaphy suture has been placed to
provide corneal protec:\ion. 1: Sagittal view of dissec:\ion planes with
orbital floor and rim elCpOsure. C: Exposed orbitul floor with hardware in plaat. D: Postoperative view of patient following repair of
left malar complex and orbital &actures with a subciliary approach
and lateral upper lid crease incision. It is critical to resuspend the
skin-muscle flap to the lateral orbital rim periosteum to prevent
lower lid malposition. (From Ellis E. Zlde MF.. Surgical approaches to
the facial skeleton, 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006, with permission.)

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

Figure 79.21 Malposition of right lower eyelid following repair

of right orbital fracture through a transcutaneous approach. This
may be due to unrecogni!Qd lid laxity, failure to resuspend the
skln-musde flap, or excessive scar contracture.

lid OibiaJlaris. It has been suggested that a lower lid crease,

or subtusaL incision may have a lower incidence of malposition presumably because the pretaJ:sal omicularis sling is
not tmumatized (6,15). l..owa' lid malposition can lead to
corneal ezposure, epiphora from a displaced puncta,. and aesthetic defonnity, which may need complicated surgical repair.
If an ectropion is seen in the early postope:tative period, one
should initially treat it with massage and perhapa judicious
corticosteroid injections. On occasion. corrective surgery
with scar release, skin or mucosal grafting, and lateral canthal
tightening may be necessary. Proper susperu~ion of the skinmuscle ftap as desaibed and closure of the incision under
no tension will help to limit this outcome and can allow for
exceUentaesthetic and functional results (Pig. 79.20).

LOWER MIDFACE AND MAXILLA

The upper labial sulcus approach provides for exposure ofthe
lower midface including the pyriform aperture, medial maxillaJ:y buttresses, and late:tal maxillcu:y buttresses (Fig. 79.22).
This approach allows the surgeon to visualize the midface
from the maxillaJY alveolus up to the infraOibital rim and
from the malar eminence to the nasal bones (16). the incision is placed 5 to 10 mLabove the gingiva and extended :from

1187

the midline to as far late:tal as needed based on the needs of

the fracture exposure. One must be certain to place the incision high enough to not devitalize the gingiva around the
teeth. The indsion is made sharply dawn through the periosteum and subperiosteal elevation is begun. The infraomital
nerve must be identified early and carefully preserved. Release
along the pyriform aperture can be done taking care to avoid
perfomtion into the nasal cavity. Laterally, the periosteum
is fumly adhermt to the bone where the masseter muscle
attaches to the lateral maxilla and malar eminence. and this
will need to be sharply released in order to visualize the superior lateral butlress and medial zygoma. The dissection can
continue upward to expose the infraomital rim as needed. If
the labial sulrus approach is needed bilaterally, one should
try to maintain some of the soft tissue attachments ofthe alar
bases as these will tend to late:talize iffully released and may
cause some ftaring of the nostrils. If wide release is needed
across the midline. then this flaring should be corrected at
the time of closure with cinching sutures (Fig. 79.23). Once
the repair is complete, the incision is closed with interrupted
resorbable sutures taking care to incoipOrate the periosteum
to help prevent woWld dehiscence
Complications of the sublabial approach are uncommon. 1hey include wound dehiscence and implant exposure. This is most likely to occur laterally over the lateral
maxillary buttress hardware. If the incision is placed too
low, then some necrosis of the gingiva can occur leading
to periodontal disease. lnjw:y to the infraomital nerve can
result in permanent facial and dental anesthesia as well as
prolonged facial pain. Careful indsion placement, careful
dissection aroWld the infraorbital foramen, and meticulous wound closure should minimize these problems.

Mandibular Exposure
Transoral Approaches
The majority of mandibular fmc:tures can be exposed
through the oral mucosa. this includes symphyseal and
parasymphyseal fmctures, noncomminuted body fmctures,

Figure 79.22 Upper labial sulcus approach. A: The incision is made leaving a cuff of gingival above
the teeth. 1: Subperiosteal elevation is performed to widely expose the fracture, taking care to identify and preserve the infraorbital nerve.

1188

Section V: Trauma

c
D

Figunt 79.22 (Continued) Upper labial sulcus approach. C:

Intraoperative photo of labial sulcus exposure of maxillary fractures.
D: Intraoperative view of lateral maxillary buttress hardware placement. E: Extensive bilateral maxillary han:lwure placement for
LeFort fractures via bilateral labial sulcus approach. (Parts A and
B from Ellis E, Zide MF.. Surgical approaches to the facial skeleton,
2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006, with
pennission.)

Figure 79.23 Technique of alar dnching sut'Ure to prevent ftarlng or widening of the alar base following bilateral labial sulcus
exposure. (From Ellis E, Zlde MF.. Surglc:alapproaches to the fadal
skeleton, 2nd ed. Philadelphia, PA: Lippincott Wllllams & Wilkins,
2006, wlth permission.)

ramus and subcondylar fractures, and some condylar fractures. A ttansoral incision eliminates a visible scar, allows
identification and preservation of the inferior alveolar
nerve, and provides wide exposure of the fractures. A major
disadvantage of inttaoral incisions is that the lingual cortex
iJ not easily seen. and thus, three-dimensionally accurate
reduction of fractures may not occur since thiJ cortex iJ not
visualized. This is particularly true in the case of symphyseal and parasymph:yseal fractures that are prone to lateral
splaying. Ifthe lingual cortex is not fully reduced, then posterior widening of the mandible may occur. In addition,
since most fixation plates are placed along the inferior
border of the mandible. the alveolar nf!I'Vle may be at more
somewhat greater riJk as the dissection is from above and
must extend below and around the nerve.
Most inttaoral incisions are made in the labial sulcus
and should presen-e a viable cuff of gingiva Sharp dissection extends under the periosteum and is extended as need
to fully expose the fracture and to allow room for placement of the fixation hardware (Fig. 79.24). The alveolar
nerve iJ carefully identified and prese:rved. In the symphyseal region, the dissection can extend under the inferior border of the mentum to allow some visualization of

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

the inner cortex reduction. Following the fracture reduction and hardware placement. the incision is dosed with
interrupted resomable sutures that should include the
periosteum for strength.
In the region of the angle and ramus, the incision is
placed along the anterior border of the ramus (Fig. 79.25).
Subperiosteal elevation is done as needed and can be done
on both the inner and outer surfaces to allow visualization
for acauate fracture reduction. This approach can also be

1189

combined with endoscopic visualization, which can assist

reduction and fixation of subcondylar fractures (17, 18).

Transcutaneous Approaches to the Mandible

Some mandibular fractures may be better approached
through the neck or facial skin rather than tJansor.illy.
Severely comminuted fractures may require laJge reconsuuction hardware and primary bone grafting and are usually
best treated through a cutaneous approach. This is especially

Figure 79.24 Transoral exposure of the mandible~ 'Nfth labial sui

cus approach. A:. Incision plaOiilmcant. 1: Subpcariosteal exposure
with ldcant:lfia.rtfon of the ITICintal nerve. C: lntraopcaratin exposure
of left ant:Cirior body fractures. D: Intraoperative view of hardware
plaOiilment. Now plaOiilment of plate along lnfcarior border of the
mandible with presC~rvatlon of the mcantal nerve. E: Intraoperative
vlcaw of repair of parasymphySCial fractures with lag screws placed
via bllllt:Ciral sulcus approaches. (Parts A and Bfrom EJils E. Zlde MF.
Surgical approaches to the facial skeleton, 2nd ed. Philadelphia,
PA: Lippincott Williams 8t Wilkins, 2006, with permission.)

1190

Section V: Trauma

6
Figure 79.25 Transoral &lqXISUre of mandibular angle fractures. A:. Artist's dapic:\ion of incision along
anterior border of the ramus and wide subperiosteal &JCPD'ure. B: lmraoperative view of hardware
placed along superior border of the angle and ramus. (Part A from Elli' E, Zide MF.. Surgical approaches
to the facial skeleton, 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006, with permission.}

true in the body and angle regions. On occasion, a large

laceration may be employed for exposure. H~ one
should avoid the temptation to significantly enluge existing
lacerations unless they are optimally located and emmion
will not endanger neiVeS or woDen the cosmetic outcome.
The symph~is can be approached through. an extended
submental incision placed in the submental crease. This
is similar to that used in chin augmentation but typically
is longer as wider exposure is needed. Sharp dissection is
carried down to the bone and subperiosteal dissection is
extended as needed. This is quite straightforward with fuw
ris:b except for potential injwy to the alveolar nerve. The
principle advantage compared to an intraoral approach is
that the inner cortex can be well visualized from below and
that may assist accurate fracture reduction. The majority of
symphyseal and parasymphyseal fractures are well managed with the intraoral approach.
The coune of the marginal mandibular nerve mwt be
well Wlderstood to perform transcutaneous exposure of
the mandible. After the marginal mandibular branches
of the facial nerve exit the substance of the parotid, they
coUI1e anteriorly where they inner:vate the lower lip depressor mwdes. Early anatomic studies (19) demonstrated
that the maiginal branch dropped below the inferior border of the mandible behind the facial artery in leu than
20% of people. More recent studies have foWld, howeva;.
that in approximately half of people. the nerve dips up to
1.2 em below the mandible until it crosses over the facial

arteiy (20). In front of the facial artery, however, the mar-

ginal nerve is virtually alway& above the inferior border.

Injury to the nerve will denervate the lower lip depressors

resulting in elevation of the affected side with animation
(Fig. 79.26). This deformity is permanent and very difficult to correct or camouflage. For this reason, most have
advocated placing the incision at least 1.5 an, or approximately two finge:rbreadths, below the inferior border
of the mandible wually following a natural skin crease

Figure 79.26 Clinical example of cW'ormlty cauSQd by Injury to

the right marginal mandibular nerve. This Injury wcaakens the de
pressor musdes of the lower llp, which causes the lowcar lip to rise
leading to a aooked smile.

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

(Fig. 79.27). Dissection is carried through the skin, the

subcutaneous fat, and the platysma. Blunt dissection under
the platysma muscle extends up to the inferior border of
the mandible, and if needed, the facial artf!ry and van can
be ligated and divided for exposure. The cemcal fascia is
opened at least 1.5 em below the inferior border of the
mandible especially posterior to the mandibular notch
again to avoid injuring the matginal nerves. The submandibular gland will usually be seen and is gmtly retracted
inferiorly. The periosteum is opened and elevated, and the
masseteric fiben are released as needed for exposure of
the angle and ramus. This approach will allow exposure
from the posterior ramus, across the angle and up to the
anterior body. This approach can also be extended across

1191

the midline to the contralateral side in those unusual

c:alles where complete exposure of the mandible is needed.
Following the repait the wound is dosed in layen including the fascia and platysma. A passive drain can be placed
if desired, but suction drains should be avoided as they
can pull oral contaminants down into the wound and may
encourage the development of oral-cutaneous :fiswlae.
A retromandibular or preauricular approach can also be
employed for mended exposure of the mandibular ramus
and condylar region (Fig. 79.28) (21-23). 1he retromandibular approach typically employs a vertical incision placed
directly over the posterior border of the ramus below the
ear. The preauricular approach employs a curvilinear incision along the preauri.cular crease, around the lobule, and

D
Figure 79.'Z7 Submandibular approach to the mandible. A:. lndslon placement. Incision Is oriented
to follow relaxed skin tension lines In the neck: typically 1.5 to 2 an below the mandible. The platysma
Is Incised along the length of the Incision. 1: Exposure of mandible Is accomplished but dividing the
superflcial and deep layers of the cervical fascia. The fascia Is opened at least 1.5 em below the Inferior
border of the mandible to avoid the marginal branche.s of the facial nerve. The facial artery and vein
may be ligated If needed. C: Intraoperative view of mandibular angle fracture repair wft:h hardware In
place. D: Elmlnslve bilateral exposure of the mandible for severe bilateral comminuted body fractures
with extended submandibular approach. {Parts A and B from Ellis E, Zlde MF. Surgical approaches to
the facial $keleton, 2nd ed. Philadelphia, PA: Lippina:Jtt Williams 8t Wilkins. 2006, with permission.}

1192

Section V: Trauma

Figure 79.28 Ratromandlbular and rhytidectomy approach. A:. Mociflcld pnaaurlrular nltromandlbwr lnd
sian for expos~n of the! ramus and subcondylar area.
II: Elcposuno~ of the! ramus with nltromandlbular approach.
C: Rhytidectomy Incision approach for ramus and subcondylar arus. D: lntraopenrt.fve view of hardw!n In place
through a 1'8trom8ndlbular approach. (Pal1s B and C frcm
Ellis 1:_ Zlde MF. Swglc:tJI spprolKhes to the fsdal 8celeton,
2nd ed. Philadelphia, PA: Lippit'ICXltt Williams a. 'Wikins,
2006, with permission.}

Chapter 79: Surgical Approaches to the Craniofacial Skeleton

extending up the postaurirular sulrus as one would use in
a face-lift or rhytidectomy. The advantage of the face-lift
incision is that it leaves a more aesthetically pleasing scar.
Howeve~; the subcutaneous dissection is more extensive and
closure is more involved. The incision extends through the
skin and subcutaneous tissues and flaps are raised as needed.
Dissection continues down through the SMAS and the
parotid fascia. At this point, dissection is done with purely
blunt technique with spreading of the parotid tissues toward
the posterior border of the ramus of the mandible. The marginal nerve branches may be seen and should be meticulously protected with gentle retraction either superiorly or
inferiorly as needed. The retromandibular vein is identified
and ligated as needed. The masseter muscle fibers are incised
and elevated to gain exposure of the posterior border of
the ramus, and then subperiosteal dissection is extended as
dictated by the fracture repair. The greatest concerns of this
approach are the risks to the facial nerve and the potential
for a salivary fistula from the divided parotid tissues. The
marginal nerve is at greatest risk, but typically the marginal
nerve can be identified and protected. Temponuy paresis or
weakness of the marginal nerve is common and likely is due
to retraction of the neiVe during exposure during the fracture
repair. Closure is done in layers including the periosteum,
masseteric fibers, SMAS, and skin. A passive drain may be
used, but again active suction drains should be avoided.

1193

Gende soft tissue handling and judicious electrocautery will minimize scarring and hair follicle damage.
The surgeon must be intimately familiar with the
location, course. and depth of the facial and trigeminal nerves.
Consider camouflaging the scalp coronal incision
with curvilinear design in the parietal regions and
bevel incisions parallel to the hair follicles.
Preserve or enhance lower eyelid support and utilize
techniques that will suspend the lower lid tissues
during healing to prevent lower lid malposition and
ectropion. Transconjunctival approaches may be
less prone to postoperative lid malposition.
Preserve an adequate cuff of viable gingival tissue
when making intraoral incision to expose the maxilla
or mandible. Identify and preserve the mental nerve.
Consider transoral approaches for all mandible
fractures except those that have severe comminution that will require extensive hardware or bone
grafting.
Be cognizant of the anatomy of the marginal mandibular nerve with all transcutaneous approaches to
the mandible.
Endoscopic visualization may assist the repair of
orbital floor, frontal sinus, zygomatic arch, and
mandibular condylar fractures.

SUMMARY
Contemponuy management of facial skeletal trauma
demands that the surgeon carefully diagnose. expose. and
repair the facial skeleton with precision and anatomic
accuracy. Surgical exposure should be performed with
careful soft tissue handling techniques and with aesthetic
surgical concepts in mind. The incisions should be carefully designed and placed and should follow relaxed skin
tension lines whenever feasible. Dissection should follow proper anatomic planes. The surgeon should have a
thorough understanding of the anatomy of the facial and
trigeminal nerves and carefully avoid and protect them.
Meticulous wound closure and tissue resuspension should
minimize postoperative soft tissue deformities. If these
basic concepts are observed, the facial trauma victim can
expect an excellent recovery-hopefully with few long-term
soft tissue consequences and minimally visible incisions.

Thoroughly counsel patients preoperatively regarding the exact location of all planned incisions, the
risks of each approach, and postoperative care and
the possible need for future scar revision.
Incisions should be planned with relaxed skin tension lines and natural skin creases in mind.

RECOMMENDED READING
Ellis E, Zide ME SufXical aflProaches to the facial skeleton, 2nd ed.
Philadelphia. PA: lippincott Williams & Wilkins, 2006. This is an
excellent, oomprehensive text, which ccwers the topic of approaches to
the craniofacial skeleton in great detail. The text is enhanced by clear
illustrations, cadaver dis,ections and intraoperative photographs. This
text is highly recommended for all facial trauma surgeons both novices and experts.

REFERENCES
1. Zhang QB, Dong YJ. Zhao JH. Coronal incision for treating
zygomatic complex fractures. J CraniomaXJ11ofac Surg 2006;34:
182-185.

2. Fox AI. Thtum SA. The coronal incision: Sinusoidal, sawtooth,

and postauricular techniques. Arch Facial Plast Su71 2003;5:
259-262.
3. Wilhelmi BJ. Mowlavi A. Neumeister MW, et al. Facial fracture
approaches with landmark ratios to predict the location of
the infraorbital and supraorbital nerves: an anatomic study.
J Cmniofac Su71 2003; 14:473-477.
4. Evans BG, Evans GR Zygomatic fractures. Plast Reconstr Surg
2008;121:1-11 .
5. Frodel JL Jr. Rudderman R. Facial soft tissue resuspension following upper facial reconstruction. J Cmniomtm1lofac Jtauma
1996;2:24-30.
6. Ridgway EB, Chen C, Colakoglu S, et al. The incidence oflower
eyelid malposition after facial fracture repair: a retrospective study and meta-analysis comparing subtarsal. subciliary,
and transconjunctival incision. Plast Reconstr Surg 2009;124:
1578-1586.

1194

Section V: Trauma

7. Salgarelli AC, Bellini P. landini B, et al. A comparative study of

different approaches in the treatment of orbital trauma: an experience based on 274 cases. Oral Maxillofac Surg 2010;14:23-27.
8. ApplingWD, PatrinellyJR. Salzer'D\. Transconjunctival approach
vs. subciliary skin-muscle flap approach for orbital fracture
repair. Arch Otolaryngol Head Neck Surg 1993;119:1000-1007.
9. Patel PC, Sobota BT, Patel NM, et al. Comparison of transconjunctival versus subciliary approaches for orbital fractures: a
review of 60 cases. J Cranioma;n1lofac Surg 1998;4: 17-21.
10. Ridgway EB, Chen C, Lee BT. Acquired entropion associated with
the transoonjunctival incision for facial fracture management.
1 Cranwfac surg 2009;20:1412-1415.
11. Mullins JB. Holds JB. Branham GH, et al. Complications of
the transconjunctival approach: a review of 400 cases. Arch
Otolaryngol Head Neck Surg 1997;123:385-388.
12. Goldberg RA. Mancini R. Derner JL.TheTranscaruncularapproach:
surgical anatomy and technique. Arch Faciall'fast Surg 2007;9:
443-447.
13. Graham SC, Thomas RD. Carter KD, et al. The lhmscaruncular
approach to the medial orbital wall. Laryngoscope 2002; 112:
986-989.
14. Rohrich RJ. Janis JE. Adams WP. Subciliary versus subtarsal
approaches to orbitozygomatic fractures. Plast ReconstT Surg 2003;
111:1708-1714.

15. Bahr W. Bagambisa FB, Schlegel G, et al. Comparison of

transcutaneous incisions used for exposure of the infraorbital
rim and floor: a retrospective study. Plast Reconstr Surg 1992;
90:585-589.
16. McRae M. Frodel JL. Midface fractures. Facial Plast Surg 2000;16:
107-113.
17. Schubert W. Jenabzadeh K . Endoscopic approach to maxillofacial
trauma. J Cranwfac Surg 2009;20: 154-156.
18. Kellman R. Cienfuegos R. Endoscopic approaches to subcondylar
fractures of the mandible. Facial Plast Surg 2009;25:23-28.
19. Dingman RO, Grabb we. Surgical anatomy of the mandibular
ramus of the facial nerve based on dissection of 100 facial halves.
l'fast Reconstr Surg 1962;29:266-272.
20. Myckatyn TM, Mackinnon SE. A review of facial nerve anatomy.
Semin Plast Surg 2004;18:5-12.
21. Girotto R. Mancini P, Balercia P. The retromandibular transparotid approach: our clinical experience. J Craniomaxillofac Surg
2012;40: 78-81.
22. Thng W. Gao C, Olng J. et al. Application of modified retromandibular approach indirectly from the anterior edge of the parotid
gland in the surgical treatment of condylar fracture. J Oral
Maxs11ofac Surg 2009;67:552-558.
23. Ellis E. Condylar process fractures of the mandible. Faciall'fast
Surg 2000; 16: 193-205.

Brett A. Miles

Jesse E. Smith

Mandibular fractures represent common injuries and are

second only to nasal fractures with regard to frequency.
The central role of the mandible in mastication, swallowing, and speech makes the surgical management and
rehabilitation of mandibular fractures challenging. In
addition, complications related to the management of
mandibular fractures, while seldom life threatening, often
result in significant morbidity for patients with these
injuries. Therefore, accurate assessment of the injury and
the appropriate application of the priniciples of the management of mandibular fractures is critical for sucessful
outcomes.

maxillary first molar is used as a reference (Fig. 80.2). Class

I occlusion is the most commonly observed pattern. Class
II represents retrognathism, and class III represents prognathism. Cognizance of the three classes of occlusion and
careful examination of the cuspal interdigitation and wear
facets allow accurate restoration of the patient's preinjury
occlusion. Restoration of the patient's occlusion is the primary goal during the surgical management of mandibular
fractures as well as during postoperative rehabilitation. The
universal dental numbering system is useful in describing
the location of mandibular fractures and reporting associated dental injuries (Fig. 80.3 ).

ANATOMY

BIOMECHANICS OF THE MANDIBLE

The mandible articulates with the skull base at the paired

temporomandibular joints (TMJs) and is suspended
by a complex ligamentous and neuromuscular apparatus. Because of this unique, bilateral articulation with
the skull base and the vector of forces contributing to
mandibular trauma. a bilateral fracture pattern is commonly observed. The anatomic components of the mandible include the symphysis, parasymphysis, body, angle,
ramus, coronoid process, condyle, and alveolus (Fig.
80.1 ). Anatomic locations with an increased propensity
for fracture include the third molar area (especially if the
third molar is impacted), the mental foramen region, and
the condylar neck. Edentulous, atrophic mandibles are
inherently susceptible to fracture in multiple anatomic
locations. Additionally, pediatric patients in the deciduous phase of dentition are prone to mandibular fracture,
the result of weakening of the mandible due to the presence of unerupted teeth.
Knowledge of dental occlusion is integral to the diagnosis and management of all facial fractures. In the Angle
classification of occlusion, the mesiobuccal cusp of the

Biomechanically, the mandible can be considered a cantilever beam. The beam is suspended at two points, which
represent the TMJ attachments. In the mandibular body
and angle, occlusal forces produce zones of relative tension along the superior border and compression along the
inferior border. Mandibular tension-compression stress
distribution is complex, and stress distribution can vary
dramatically, depending on the magnitude and point of
force application. In the symphyseal area. the situation is
more complicated when the mandible is viewed and tested
as a three-dimensional model. Compression is produced
at the upper border. and tension and torsional forces exist
along the lower border. These three-dimensional stress
relationships are important to understand, because tension and compression forces dictate the type of fixation
applicable to a particular fracture.
Angle and body fractures can be classified as either vertically or horizontally favorable or unfavorable (Fig. 80.4).
Fractures are classified as favorable when muscles tend to
draw the fragments toward each other, thus, reducing the
fracture. Fractures are described as unfavorable when the

1195

1196

Section V: Trauma

EVALUATION AND DIAGNOSIS

History
Pain and malocclusion after a blow to the lower face
strongly suggest mandibular fracture Additional symptoms include anesthesia or paresthesia of the lower lip and
chin caused by trauma to the inferior alveolar nerve u it
courses through the mandibular canal (Table 80.1).

Physical Examination

Figure 80.1 The anatomic components of the mandible lndude

the symphysis, parasymphysis, body, angle, ramus, coronoid
process, condyle, and alveolus. 1, Condylar process; 2, Coronoid
process; 3, Ramus; 4, Alveolar process; 5. Parasymphysls;
6, Symphysis; 7, Mental foramen; B, Body; 9, Inferior alveolar
nerve; 10, Angle.

fragments tend to be displaced by muscular forces. The

majority of mandibular angle frac:tures are horizontally
unfavorable as the mass~ medial pterygoid, and temporalis muscles contribute to the superior and medial displacement of the proximal segment Vertically unfavorable
angle fracturelJ result in medial displacement of the proximal segment by the pterygoid musculature Vertically unfavorable fractures of the body of the mandible are distracted
by the mylohyoid and suprahyoid musculature A careful
assessment of the biomechanical pattml of the fracture is
paramount to guide surgical management in order to prevent displacement of fragments due to inadequate fixation
teclmiques.

Figure 80.2 The Angle dasslflcatlon

of occlusion Is based on the relation of
the mesiobuccal cusp of the maxillary
first molar to the buccal groove of the
mandibular flrst molar.

FracturelJ of the symph.yBis-parasymph:ysis and body can

be accompanied by malocclusion, palpable tenderness,
altered sensation, gingival lacerations/dental trauma.
hematoma in the floor of the mouth, or loss of normal
facial contours. Mobility of fractures in these locations is
often identified with manipulation. Trismus is a relatively
common finding with mandibular fracwres, but it also
occu:m after zygomaticomaxillary complex fracturel!l and
with facial contusions without evidence of fracture The
maximal interincisal opening (MIO) of a patient with a
mandibular fracture can be markedly reduced secondacy to
pain, muscle splinting, or impinging fragments. The normal MIO in a healthy adult is approximately 4C to 50 mm.
Fmelllres of the condyle and condylar neck are associated with impaired translational movement of the condyle
along the artiallar eminence Although limited rotation
may also occut this lack of translation produces a characteristic deviation of the chin toward the side of such a
fracture when opening as well u reduced interincisal distance (Fig. 80.5). Fractures of the neck of the condyle tend
to be displaced anteromedially in response to the action of
the lateral pterygoid muscle This displacement produces
a loss in the functional height of the ramus, resulting in

Chapter 80: Mandibular Fractures

10

11

12

13

14

15

16

'iJQfiJVPp;y\ ~~~~~ Ww
32

31

30

29

28

27

26

25

24

23

22

21

20 19

18

17

Figure 80.3 The universal numbering system for the pennanent dentition begins with the maxillary right third molar. Similarly, the 20 teeth of the deciduous dentition are lettered from A to T,
beginning with the maJUIIary right second deciduous molar.

Lateral --~~
pterygoid m.

Medial--~~

pterygoid m.

c
Figure 80.4 A; Horizontally favorable fracture. 1: Horizontally unfavorable; the masseter, medial
pterygoid, and temporal is musdes contribute to the superior and medial displac:ament of the proximal segment. C: Vertically favorable fracture. D: Vertically unfavorable angle fractures result in
medial displac:ament of the pro:llimal segment by the medial and lateral ptarygoids.

1197

1198

Section V: Trauma

ID

DIAGNOSIS
MANDIBULAR FRACTURE

Malocclusion
Fragment mobility
Trismus
Deviation on opening toward side of fractured condyle
Anterior open bite connlaten~l to side of fractured condyle
Radiographic evidence of fracture
Hematoma in floor of mouth
Laceration of attached gingiva overlying fracture site

premature contact of the ipsilateral molar teeth. The point

of contact acts as a fulaum and produces a characte:risti.c
open bite on the side opposite the fracture (Fig. 80.6).
Bilateral condylarfsubcondylar fractures often produce
a symmetric anterior open bite due to the loss of vmical
height of the posterior mandible.

Radiographic Evaluation
The single best radiograph for evaluation of mandibular fracwres is the panoramic view (Fig. 80.7A-C).
Historically, mandibular series of plane radiographs (posteroanterior view, a Townes anteroposterior axial view, and
bilateral oblique views) were used to provide additional
information; howeva;. presently, computed tomography
(Cf) is used in many cente:Js (Fig. 80. 7D and E). cr scans,
while not required, have become standard in the evaluation of mandibular fractures due to increased accuracy, and
are useful in determining the fragment location and size,
degree of displacement. as well as Wldiscovered associated
fractures. Helical cr scans have been shown to accurately
diagnose 100% of mandibular fracwres, whereas initial
panoramic imaging was sensitive in 86% of cases ( 1).

Cone-beam technology o~ atremely high-resolution,

three-dimensional images of the mandible for the diagnosis of mandibular fractures as well as for evaluation of
postoperative results (2,3).

MANAGEMENT
General
The prim.aty goals when treating mandibular fractures are
to establish and maintain the preinjw:y occlusion and provide appropriate stabilization for bone healing. Surgical
management of mandibular fracwres varies based on the
location of the fracture and severity of the injury. In general, fractures involving the tooth-bearing portion of the
mandible with communication to the oral cavity are considered open. Displacement of jaw fragments is uncomfortable, impairs oral hygiene and alimentation, and
contaminates exposed bone with bacterial flora from the
oral cavity. These features warrant antibiotic prophylaxis
starting as soon as possible after the injury as well as intraoperatively; howeve~;. the benefit of perioperative antibiotics has been questioned recently (4). Postoperative
antibiotics are unnecessary in the majority of cases (5).
Topical chlorhexidine rinse may also help minimize the
bacterial contamination of the fracture site. Temporary
partial reduction via the use of wire fuation may alleviate some mobility at the fracture site in severely displaced
fractures, prior to surgical management. Although delay
of fracture repair for a short duration does not markedly
increase the infection or complication rate, consideration
of patient comfort and prolonged environmental exposure warrants timely intervention. It should also be noted
that nonmobile, nondisplaced, or incomplete fractures
may be treated with careful observation and soft diet, provided the occlusion is stable and there is no mobility at
the fracture site.

'.._--"
Figure 80.5 Fractured condyle does not translate down the articular emlnenc:e during jaw open
lng. The unopposed translational movement of the opposite condyle deviates the chin toward the!
side of the fractured condyle.

Chapter 80: Mandibular Fractures

Figure 80.6 Fractured CJDndyle distracted arrteromedially by the lateral pterygoid musde. This producas a shortened functional height of the ramus as Ute masseter, medial pterygoid, and temporalis musdes draw the ramus
doser to the skull base. The ipsilateral molar teeth act as a fula-um to produca a slight CJDntralm:eral open bite.

D
Figure 80.7 A: Panoramic radiograph of symphyS881 fract:una and left subcondytar fract:una.
B: Panoramic radiograph of right body fractuna and left parasymphysaal fractuna. C: Postoperative pan
oramlc radiograph after open reduction Internal fixation of fract:unas In B. Note the location of the nacon
structlon plate along the Inferior border. Small lag scnm was also used In this case for oblique section of
the body fraduna. D: Axial CT scan of moderately dlspi&CIIId left mandibular body fractuna. (Contlnl.ltild)

1199

1200

Section V: Trauma

OPEN REDUCTION INTERNAL

FIXA110N OP110NS FOR ADULT
DENTATE PATIENTS

Fracblre Location

ORIF

Symphysis and
parnymphysis

Inferior plate and arch bars

Inferior locking or nonlocking
reconstruction plate
Inferior locking or nonlocking 2.0mm
mandible plate and superior border
monocortical tension band
Two 2.0.mm miniplates (8)
Two lag scnrws (9)
Inferior plate and arch bars
Inferior locking or nonlocking
reconstruction plate
Inferior locking or nonlocking 2.0mm
mandible plate and superior border
monocortical ten5ion band
Two 2.0.mm miniplates (8)
Multilag screw technique, if oblique
Single malleable 5Uperior border
miniplate (11)
Two biplanar or monoplanar miniplates

Body

E
FiguN 80.7 (Continued) E: Coronal CT of laterally displae~~d
right subclCindylar fracture.

Angle

(12)

Closed Reduction
Many favorable fractures in adult patients can be managed by means of closed reduction with ardt bars, bone
screw&, or other means of intermaxillary fixation (IMF).
Four to six weeks of IMP is generally considered appropriate for the symphysis, angle, and body. Considerable
variation among experts exists regarding the duration of
IMF for condylar fractures to optimize condylar mobility while achieving osseous union. Longer periods
of IMF (4 to 6 weeks) have been associated with poor
range of motion, ankylosis at the TMJ, muscle atrophy,
and loss ofinterincisal opening (6). Nevertheless, many
condylar fractures are successfully managed with dosed
tedtniques (7). Closed reduction techniques are still
commonly used for fractures in dtildren involving the
developing dentition and in nonmobile. nondisplaced
fractures. 1he indications for closed reduction vary
widely; however, closed techniques should be utilized for
cases in whidt an open reduction is either unnecessary or
contraindicated.

Open Reduction
Table 80.2 summarizes treatment options for open reduction with internal :fixation (ORIF) for mandibular fracwres
in adult patients according to fracwre location. Internal
fixation can be classified as being rigid (reconstruction
plates, lag screw&), semirigid ( miniplates), or nonrigid
(interosseous wires). Most rigid and semirigid tedtniques
obviate the use of postoperative IMP, and the occlusion
may be guided with postoperative dental elastica when

Ramus and condyle

Inferior locking or nonlocking

reconstruction plate with suparior
tension band
One 2.0.mm miniplate
Two 1.5/2.0mm miniplatas

required. This is an especially important consideration

among patients with epilepsy, diabetes, alcoholism,
psychiatric disorders, or severe disability, who may not
tolerate lMR 1he classic indication for open reduction
and rigid internal fixation is inability to reduce or stabilize the fracture with a closed tedtnique Other indications include associated midface fractures, associated
condylar fractures, IMF is either contraindicated or not
possible, to preclude the need for IMF for patient comfort. and to facilitate the patient's return to work or other
activities. 1he fundamental principles of rigid internal fixation include accurate anatomic reduction, stable internal
fixation, early mobilization, and careful tissue handling
with preservation of the neurovascular supply. 1he application of appropriately stable :fixation varies depending
on the location and severity of the fracture Internal fixation is the application of sufficient hardware to prevent
movement across the fracture site during functioni how~ this is not necessarily rigid internal fixation in many
situations. Thus the concept of load-bearing versus loadsharing :fixation merits review. Load-bearing fixation is the
application of hardware of sufficient rigidity to resist all
functional fooces until osseous union is achieved. When
treating comminuted mandibular fractures, atrophic
mandibular fractures, and those with segmental defects,
load-bearing fixation is generally required. In contrast

Chapter 80: Mandibular Fractures

1201

Selection of Hardware

load-sharing fixation refers to the application of hardware

that allows the functional load to be shared between
the hardware and the apposed mandibular cortices after
fracture reduction ia achieved along the fracture site. The
majority of mandibular fractura are adequately treated
with load-sharing fixation.
Comminuted fractures are defined as a fracture pattern
in which a single anatomic region is broken into pieces.
Comminuted fmctures of the mandible hrre been treated
in a variety of fashions, including dosed reduction, external
pin fixation, internal wire fixation, and ORIF with titanium
plating systems (8- 10). Most nonunions in these fractures
result from inadequate immobilization ofcomminuted fragments. Investigations have revealed that periosteal stripping
during ORJF does not lead to increased infections as long as
fragments are properly stabilized (9, 10). Comminuted mandibular fractures treated with fonnal ORIFusingreconstruction plates ahibit lower complication rates and decreased
recoroy time when compared to cxtemal pin fixation and
dosed reduction techniques (Fig. 80.8) (9, 10).
In terms of soft tissue approaches, similar complication
rates have been obs~d when comparing transoral venue
emaoral reduction of mandible fractures ( 11 ). The majority of mandibular fractures may be treated via the transoral
approach, which allowa direct occluaal visualization during
reduction and inte:mal fixation, eliminates facial ecarring,
and limits the risk of facial nerve injury. In many instances,
posterior body, angle, ramus, and condyle fractures can
be addressed through combined intraoral and e:maoral
approaches utilizing trocars to reduce external scars. The
main advantage of the atmoral approach is enhanced
viaualization and accas for complex or comminuted fractures. Extensive comminution or fractures in the severely
atrophic mandible often require an external approach to
appropriately address the fracture.

In comminuted, segmentaL and infected fractures, when

load-bearing fixation ia required, large reconstruction
platea using 2.4 or 2.7-mm screw& are advised (Fig. 80.8).
In general. these reconstruction plates require placement of
at least three to four screw& on either side of the fracture
within stable portions of the mandible. Locking recomtruction plates retain their yield load, yield displacement,. and
stiffness even when imprecise contouring to the bone has
oc:rurred, whereas nonlocking reconstruction plates demonstrate significant differences in these facton eren with as
little as 1 mm of displacement from the bone (12). For this
reason, many now prefer the use of locking reconstruction
platea in these situations. The benefit of locking teclmology
may be less apparent in load-sharing fixation schemes and
nonlocking plates are often sufficient (13).
Miniplates (1.5 to 2.0 mm) are commonly used for mandibular fracture repair ( 13-15). Generally, a six-hole plate
is positioned at the inferior border and bicortical screws are
placed; a four-hole plate is placed at the upper border with
either bicortical or monocortical screws to provide a tension band. Cardul attention to the location of the mental
n.eNe and tooth roots is required. Sagittal and oblique fractures may be amenable to repair with lag screw techniques.
To achieve optimal compression without displacement.
the lag screw hole must be drilled perpendicular to the
fracture (F'1g. 80.9). 1he most common indication for the
lag screw technique ia the symphyseal fracture. It should
be noted that dynamic compression plates, which produce
interftagmentary compression of bone. were historically
thought to offer an advantage over standard reconstruction
plates. Investigations have :revealed that dynamic compression may introduce unwanted forces resulting in difficulty
with hardware application, oblique fracture displacement.

Figure 80.8 Reconstruction plates (2.4 or 2.7-mm) are used In

comminuted, ~p. and infected fractures. Small fragments may
be reduced and stabilized with smaller (2.~mm) plates prior to
appllartion of the reconstruction plate.

Figure 80.9 Reduction and fiXB'tion of a symphyseal fracture and

angle fracture with lag screw technique In the symphyseal region
and superior border plate (2.0-mm) for the angle fracture.

1202

Section V: Trauma

and malocclusion ( 16). In addition. dynamic compression

does not follow physiologic principles as bone tends to
resorb under compression and therefore this technology is
rarely indicated.

Body
Fractures of the body are located between the canine and
the last molar (F'tg. 80.1). F'JXation of body fmcture!l is
accomplished by the same means as fmctures of the symphysis; howevet special attention must be directed to the
inferior alveolar/mental nerve and dentition. In addition.
the marginal mandibular branch of the facial nerve is at
risk when an external approach is utilized. Rigid fixation
can be easily applied to body fractures using a retromandibular or submandibular approach, or via an intraoral
approach with or without transbuccal trocars.
Hardware configurations for mandibular body fractures are similar to those for the fixation of symphyseal
fmctures with the exception of lag screws, which are less
commonly indicated. Anterior body fractures coursing
through the mental foramen can be managed by placing
an inferior bicortical mandibular plate (2.0 to 2.4 mm)
and a superior border monocortical tension-band plate
If the fracture occurs in an edentulous area of the body,
or an atrophic situation exists, consideration ofload-bearing fixation is recommended due to the increased leverage produced by any remaining anterior dentition on the
hardware construct.

Symphysi5-Parasymphysis
Symphysis and parasy:mphyseal fmctures are those fractures
located between the canines (see F"tg. 80.1 ). Vertically unfavorable symphyseal fractures tend to collapse the mandibular an:h in response to the medial pteiygoid and mylohyoid
musculature A rigid technique necessitates application of
an:h bars and tempor.u:y intraoperative interdental wiring to establish the proper occlusion. Open reduction
with rigid internal fixation of symphyseal fractures may be
accomplished with a variety of hardware configurations.
1hese include an inferior border contoured mandibular
fmcture plate with mandibular an:h bat;. an inferior locking
or nonloddng reconstruction plate, an inferior locking or
nonlocking 2.0-mm mandible plate and a superior border
monocortical tension band, two lag screws, or two properly placed 2.0-mm miniplates (Fig. 80.10) (15,17-20).
Inkrior border plates placed in these regions should be
slightly overbent to prevent lingual splay of the fracture
resulting in widening at the mandibular angles and tmnsverse occlusal discrepancies. Recent biomechanical investigations indicate that the lag screw technique addresses
the issue of lingual cortex reduction and likely provides
the most stable construct for symphyJeal fracture!~ (17, 18).
Nevertheless, lmowledge of multiple techniques is required
to address the variety offmcture patterns of the mandibular
symphysis for predictable outcomes.

Angle
Fractures of the mandibular angle occur posterior to the
second molar within the retromolar triangle (Fig. 80.1).
Fractures of the angle are associated with a high incidence of infection and often require ORlF due to the relatively small cross-section of bone in this region. and the

B
Figure 80.10 A:. An oblique symphyseal fracture. 1: Initial compression and reduction at thea superior mandibular border provided by the arch bar. 'The 2.0 or 2.4-mm mandibular reconstruction platQ
Is slightly owrbCint and Is applied with blcortfcal screws. Thea screws are numbCired In the order that
they should bel plaa~d.

Chapter 80: Mandibular Fractures

oblique and irregular fracture configuration. Additionally,

impacted wisdom teeth in this area increase the risk offracture, complicate treatment. and may require removal in
the event reduction is not possible or the tooth is loose
(21,22). Transoral placement of a single malleable miniplate (noncompression with 2.0-mm mono cortical screws)
along the superior border of the angle has been commonly
used with cxcdlent results (Fig. 80.11A and B) {21,23,24).
Two-miniplate rigid fixation of the angle also produces
acceptable results and can be accomplished thorough an
intraoral approach. These two miniplatea can be placed
in either a biplanar or monoplanar mann~ although
studies confirm that the biplanar method is more stable
(Fig. 80.11Aand C) (25).
The memal approach can also be used to apply a variety of hardware configurations: an inferior border locking or nonlocking reconstruction plate with or without a
monocortical superior tension plate. an i.nferior bicortical
dynamic compression plate with neutral screw placement
and a superior monocortical tension plate. or two monoplanar miniplates. These systems can be applied using an
intraoral approach with the aid of transbuccal trocan~ as
well. Although many technical variations for ORIF of mandibular angle fractures are effective, selection should be
based on the availability of equipment and the experience
of the surgeon.

Condyle
The condyle is classified as the area superior to the line
extending from the sigmoid notch to the posterior border
of the mandible (Fig. 80.1). The goals of treating condylar
fractures include normal range of motion without pain,

preinjwy occlusion. and symmeuy of the mandible. The

treatment of fractures of the mandibular condyle include
open and dosed techniques; howev~ considerable controveDy exists regarding optimal management (7,26-28).
Generally, nondisplaced condyle fractures are treated
consenratively with arch baJS and guiding elastics. Brief
periods of IMF have been advocated; howeve~;. no consensus exists regarding the optimal duration (7,29). As
noted previously, long periods of IMF can result in TMJ
ankylosis and limited opening and are therefore not recommended. Early mobilization with guiding elastics to
support the occlusion allows for return to preinjury range
of motion and increased patient comfort {6, 7). The indications for open reduction of condylar fractures remain
debatable; howeve~;. the classic indications summarized
in Thble 80.3 provide a framework for treatment consideration. Nevertheless, there are many advocatea for ORIP
of mandibular condylar fractures, as several investigations
hlM! demonstrated faster recovery with improved occlusion, excellent function, and improved facial symmetry (30,31}. Condylru;. subcondylat and ramus fractures
can each be stabilized with a single 2.0-mm mandibular
miniplate with at least two screws on each side of the
fracture line. Complications that can occur with open
treatment of condyle fractures include hematoma, facial
ne:M! damage, infection. auriculotemporal nerve d}'!function. Prey syndrome, and scarring. Recent transoral endoscopic treatment of condylar fractures offers an excellent
approach and avoids facial nerve injwy (28,32,33). The
technique requires specialized equipment and can be technically challenging until significant swgical experience
is achieved (23,25-27). It should also be noted that the
transoral technique is not without complications (34).

A
dlsplaa~me~nt. B: Transoral pl8011mCint of a single~ rnalle~able
2.0mm mlnfpiiiW with monocortfcal screws near the superior border of the angle. C: Two 2.0-mm miniplate rigid fixation
of the angle fracture plaa~d In a blplanar manner.

Figure 80.11 A:. TransvCII'SQ angle fracture with minimal

1203

1204

Section V: Trauma

Management of Teeth in the Line of Fradure

INDICATIONS FOR OPEN
REDUCTION OF MANDIBULAR
CONDYLE FRACTURES
Absolute Indications
Displacement into the middle cranial fossa
Foreign body in the joint capsule (e.g., gunshot wound)
Lateral extracapsular deviation of the condyle
Inability to open mouth or achieve occlusion after 1 week
Open fracture with the potential for fibrosis
Relative Indications
Unilateral or bilateral condylar fractures associated with
comminuted midfacial fractures
Comminuted symphysis and condyle fracture with loss of teeth
Displaced fracture resulting in an open bite or retrusion in
medically compromised, mentally unstable or retarded adults
Displaced condyle with edentulous, or partially edentulous,
mandible with posterior bite collapse
Adapted from Zide MF. Open reduction of mandibular condyle
fractures. Indications and technique. Clin Plast Surg 1989;16(1):69-76,
with permission.

Although intracapsular condylar fractures have been traditionally managed with closed techniques due to the risks
of necrosis and TMJ arthrosis, open techniques have been
applied to these situations with reasonable results, and the
optimal management remains elusive (26,27,35).

Ramus
The ramus is the area superior to the angle and inferior to
an angle formed by two lines with the apex at the sigmoid
notch (Fig. 80.1). In many situations, ramus fractures may
be treated dosed when they occur in isolation as they are seldom displaced and splinted by the ptetygomasseteric sling.
Traditional techniques of internal fixation may be used in
situations of displacement or comminution of the mandibular ramus.

SPECIAL CONSIDERATIONS
External Fixation
Historically, stabilizing mandibular defects and fractures
by external fixation was frequently used in contaminated
gunshot wounds or infections resulting in the loss of
mandibular continuity (Fig. 80.12A). Although current
locking reconstruction technology addresses many of
these situations (Fig. 80.12B), external fixation provides
the advantage of fragment stability and allows wound
debridement and stabilization prior to rigid internal
fixation and is appropriate in some situations. Following
the resolution of infection and the healing of the soft tissue envelope. reconstruction can be accomplished using a
traditional reconstruction plate with bone grafting or free
tissue transfer.

It is generally agreed that previously healthy teeth can be

left in the line of fracture if the tooth is stable and the
periodontal ligament associated with the tooth is reasonably intact. Conversely, teeth that have suffered structural
damage, periodontal ligament damage compromizing the
blood supply, or which prohibit proper fracture reduction should be removed. Removal of previously healthy
third molars in the line of angle fractures can contribute
to fracture instability and distraction and, therefore, are
retained but monitored for infection in the postoperative
period (22).

Edentulous Fradures
Edentulous fractures are more common in older patients
(Fig. 80.13). Historically, the management of an edentulous mandibular fracture was often dosed reduction in
which arch bars are applied to the dentures or Gunning
splints to allow IMF. This technique has several disadvantages including poor mandibular segment control
and poor reduction of the fracture. Current treatment of
edentulous mandible fractures is performed with open
reduction internal fixation using a reconstruction plate
in the majority of cases. Locking reconstruction plates are
generally recommended; however, multiple options have
been used with success provided load-bearing fixation is
achieved (36-38). Severely atrophic mandible fractures
(less than 10 mm vertical height) have the greatest risk of
complications, and consideration to primary bone grafting should be entertained provided there is no evidence of
active infection (39). A variety of bone grafting techniques
have been used in the treatment of atrophic mandibular
fractures, including corticocancellous iliac crest and free
tissue transfer (39-42).

Pediatric Fractures
Pediatric mandibular fractures represent a somewhat
unique situation due to the presence of the unerupted
dentition and the growth potential in this population. In
addition to providing areas of weakness prone to fracture,
unerupted tooth buds also present challenges for fixation
and screw placement. When compared to the adult situation, a significantly larger proportion of pediatric mandibular fractures can be managed by means of dosed reduction.
Some scenarios such as nondisplaced, stable fractures may
be managed with soft diet and observation. Placement of
standard archbars during the mixed dentition stage can be
problematic, and involvement of the dentist/orthodontist
to provide anchorage devices to facilitate dosed management is recommended. Functional appliance therapy with
guiding elastics, begun immediately after the injury, is useful in maintaining proper occlusion and restoring mandibular position. Rigid and open techniques are considered

Chapter 80: Mandibular Fractures

1205

Figure 80.12 A:. Application of an external fixation system allows alignment of the fracture or
defect, appropriate for some situations In which rigid Internal fixation Is contraindicated. 1: 2.4- to
2.7-mm reconstruction plate (generally locking) used to bridge a mandibular defect.

in situations of severe displacement. occlusal instability,

and comminuted :fracwres. 1he selection of hardware is
similar to the adult situation; howeve:t consideration for
monocortical techniques to avoid the developing dentition. inferior border placement of hardware. and ret~Oib
able technology is warranted to avoid complications. 1he
most dreaded complication of pediatric condyle fractures
is the development of ankylosis of the TMJ, which can
result in growth disturbances producing facial asymmetry/
deformity. Consideration for open reduction of severely
displaced, bilateral subcondylar fractures is warranted to
prevent loss of facial height, mobility, and anterior open

bite if closed techniques fail. Rtgardless of whether closed

or open techniques are utilized, early mobilization reduces
the risk of limited mobility due to :fibrosis/ankylosis, and
should be a tenet of treatment.

Removal of Hardware
The need for han:lware removal has been somewhat controversial historically; howeva;. current titanium fixation
systems are extremely biocompatible and form an intimate
association with bone that makes plate removal technically dif:fia:ilt and probably unnecessary in the majority

Figure 80.13 The atrophic, edentulous mandible

often fractures at the midbody, In thea area of minimal
bone height.

1206

Section V: Trauma

of situations. Mandibular fractures require hardware

removal more commonly when compared to midface fractures. Infection and mobility of the hardware are the most
common indications for hardware removal after ORIF of
mandibular fractures (43). In the pediatric situation, controversy continues regarding titanium plate removal with
concerns of long-term growth disturbances, systemic titanium absorption. and ..false migration of hardware during growth (44,45). Nevertheless, while hardware removal
is often recommended, the literature indicates that longterm retention of titanium hardware has minimal effects
on mandibular growth with the possible exception of the
condylar growth center ( 46,47).

COMPLICATIONS
Table 80.4lists complications of mandibular fractures. Total
complication rates have been reported at approximate rates
of 15% to 40% (16,25,34,48-50). The most common factors contributing to poor outcomes in fracture repair are
the absence of teeth, medical comorbidities, poor patient
compliance, delay in presentation. and trauma severity. The
infection rate after ORIF of mandibular fractures is about
6% to 10% provided appropriate preoperative antibiotics
are administered. As noted previously; postoperative antibiotics are likely unnecessary in the majority of cases (5).
Marked malocclusion immediately after rigid fixation is usually caused by an error in fragment alignment and is permanent unless corrected by prompt revision swgery. Standard
orthognathic surgical techniques can be used to correct malocclusion caused by late malunion of jaw fractures. Although
posttraumatic 'IMJ ankylosis is rare with mobilization, the
true incidence of'IMJ dysfunction after mandibular fracture
is difficult to establish. There are, howem; fracture patterns
related to the condyle, which likely result in significant joint
disturbance (51). Sensory disturbances of the inferior alveolar nerve are relatively common after mandibular fracture,
but traumatic neuroma formation is rare.

EMERGENCIES
Emergencies related to mandibular fractures are relatively
rare and are listed in Table 80.5. Bilateral fractures of the
mandibular body can cause posterior displacement of
the anterior mandibular arch owing to the presence of
the suprahyoid musculature. This can precipitate airway
compromise, especially when the patient is in the supine
position. Immediate intervention is required to establish
a stable airway and includes patient repositioning, wire
stabilization, intubation. or tracheotomy. Cerebrospinal
otorrhea can herald displacement of a condylar head into
the middle cranial fossa. Such an injury can be associated
with a dural tear; neurosw:gical consultation and prompt
ORIF is recommended. Concomitant injury to the adjacent
internal carotid artery occasionally occurs in conjunction
with fractures of the condylar neck. A severely displaced
fracture can prompt further radiologic investigation of the
adjacent carotid artery. Gross hemorrhage rarely accompanies mandibular fracture, but troublesome bleeding occasionally arises from the inferior alveolar artery within the
mandibular canal. ligation of this vessel is difficult. and
temporary reduction of the fracture effectively tamponades
the bleeding site.

FUTURE CONSIDERATIONS
Further improvements in endoscopic and hardware technology will drive improvements in the treatment of facial
fractures (28,32,34,52). Resorbable fixation systems for
internal fixation are an attractive option in the treatment
of adult and pediatric mandibular fractures and is currently
under investigation (53,54). Improved imaging modalities,
stereotactic image guidance, and medical modeling will
likely improve the treatment of acute fractures and the
correction of late deformities. Improved biotechnology,
such as bone morphogenetic protein, will likely contribute
to improved bone healing in these situations (55-58).

'Ill COMPUCA110NS
.... MANDIBULAR FRACTURES
Infection
Malocclusion, malunion, non!M"'ion
TMJ ankylosis
TMJ dysfunction
Sensory d isturbances of inferior alveolar nerve
Trismus
Tooth loss
Facial nerve damage
Poor cosmetic outcome

W EMERGENCIES
L!.; MANDIBULAR FRACTURES
Airway obstruction
Condylar displacement into middle cranial fossa
Adjacent injury to internal carotid artery
Hemorrhage
Severed facial nerve
Anesthesia or paresthesia of lower lip and chin

Chapter 80: Mandibular Fractures

Fractures of the condylar neck are associated with

anteromedial displacement of the condyle owing to
the action of the lateral pterygoid muscle.
Unilateral condyle fractures produce a characteristic
open bite on the side opposite the fracture.
During opening, the chin deviates toward the side
of a fractured condyle.
Bilaterally displaced fractures of the condyles are
associated with a symmetric anterior open bite.
Almost all fractures of the mandibular angle are
unfavorable and necessitate open reduction.
Vertically unfavorable angle fractures result in medial
displacement of the proximal fracture segment
Normal maximal interincisal opening is approximately 40 to 50 mm.
The majority of stable teeth in the line of a mandibular fracture are preserved.
Posttraumatic ankylosis of pediatric condylar fractures produces severe functional disturbances and
developmental facial asymmetry.
Bilateral fractures of the mandibular body, especially in edentulous patients, can allow the anterior
arch of the mandible to fall posteriorly and may
obstruct the airway.
When malocclusion is detected immediately after
open reduction with rigid fixation, revision surgery
is indicated to correct errors in fracture alignment.

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5. Miles RA. Potter JK. Ellis E III. The efficacy of postoperative
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10. Ellis E III, Muniz 0, Anand K. Treatment considerations for

comminuted mandibular fractures. I Oral MflXI11ofac Surg
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14. Sauerbier S, Knenz J, Hauptmann S, et al. Clinical aspects of a
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16. Thovinen V. Norholt SE, Sindet-Pedersen S, et al. A retrospective analysis of 279 patients with isolated mandibular fractures treated with titanium miniplates. I Oral Maxillofac Surg
1994;52(9}:931-935;discussion 935-936.
17. Oliveira TR. Passeri lA Mechanical evaluation of diffurent techniques for symphysis fracture fixation-an in vitro polyurethane
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20. Ellis E III, Graham J, Use of a 2.0-mm locking plate/screw system for mandibular fracture surgery. I Oral Maxillofac Surg
2002;60(6 ):642-645;discussion 645-646.
21. Dodson TB. 1hird molars may double the risk of an angle fracture of the mandtble. Evid Based Dent 2004;5(3}:78.
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MaxiUofac Surg 2002;60(8):863-865;discussion 866.
23. Ellis E III. Management of fractures through the angle of the
mandible. Oral MaxiUofac Surg Clin North Am 2009;21(2):
163-174.
24. Haug RH, Fattahi IT, Goltz M. A biomechanical evaluation of
mandibular angle fracture plating techniques. I Oral MaxiUofac
Surg 2001;59(10}:1199-1210.
25. Fox AJ. Kellman RM. Mandibular angle fractures: two-miniplate
fixation and complications. Arch Facial Plast Surg 2003;5(6):
464-469.
26. He D, Yang C, Chen M, et al. Intracapsular condylar fracture of
the mandible: our classification and open treatment experience.
I Oral Maxillofac Surg 2009;67(8):1672-1679.
27. Schneider M, Erasmus F. Gerlach KI. et al. Open reduction and
internal fixation versus dosed treatment and mandibulomaxillary fixation of fractures of the mandibular condylar process:
a randomiz.ed, prospective, multicenter study with special
evaluation of fracture level. I Oral MtlXI11ofac Surg 2008;66(12):
2537-2544,
28. Haug RH, Brandt MT. Closed reduction. open reduction, and
endoscopic assistance: current thoughts on the management of
mandibular condyle fractures. Plast Recorutr Surg 2007;120(7
Suppl2):90S-102S.
29. Ellis E IIL Simon P, Throckmorton GS. Occlusal results after open
or dosed treatment of fractures of the mandibular condylar process. I Oral MflXI11ofac Surg 2000;58(3):260-268.
30. Haug RH, Assacl IA. Outcomes of open versus dosed treatment of mandibular subcondylar fractures. I Oral Maxillofac Surg
2001;59(4):370-375;discussion 375-376.
31. Ellis E IlL Throckmorton G. Facial symmetry after dosed and
open treatment of fractures of the mandibular condylar process. I Oral Max~1lofac Surg 2000;58(7}:719-728;discussion
729-730.

1208

Section V: Trauma

32. Lauer G, Pradd W. Schneider M, et al. A new 3-dimensional plate

for ttansoral endoscopic-assisted osteosynthesis of condylar neck
fractures. J Oral Max~11ofac Surg 2007;65(5):964-971.
33. Schon R. Schramm A. Gellrich NC, et al. Follow-up of condylar
fractures of the mandible in 8 patients at 18 months after transoral endoscopic-assisted open treatment. J Oral Maxillofac Surg
2003; 61 (1) :49-54.
34. Kang SH, Choi EJ. Kim HW, et al. Complications in endosropicassisted open reduction and internal fixation of mandibular condyle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2012;113(2):201-206.
35. Wiwanitkit V. High cervical transmasseteric anteroparotid
approach for low subrondylar fract:ure of mandible. J Oral
Maxillofoc Surg 2010;68(4):951;author reply 951-952.
36. Muller S, Btrrgers R. Ehrenfeld M, et al. Macroplate fixation
of fractures of the edentulous atrophic mandible: immediate function and masticatory rehabilitation. Oin Oral Investig
2011;15(2):151-156.
37. Madsen MJ, Haug RH. A biomechanical romparison of 2 techniques for reconstructing atrophic edentulous mandible fractures. J Oral MaxiUofac Surg 2006;64(3):457-465.
38. Mugino H, Takagi S, Oya R. et al. Miniplate osteosynthesis of fractures of the edentulous mandible. Oin Oral In!lfltig
2005;9(4):266-270.
39. Tiwana PS, Abraham MS, Kushner GM, et al. Management of
atrophic edentulous mandibular fractures: the case for primary
reconstruction with immediate bone grafting. J Oral Maxillofac
Surg 2009;67(4):882-887.
40. Melo AR. de Aguiar Soares Carneiro SC, Leal JI.. et al. Fraaure
of the atrophic mandible: case series and critical review. J Oral
Maxillofoc Surg 2011 ;69 (5): 1430-143 5.
41. Louis P. Holmes J, Fernandes R. Resorbable mesh as a
rontainment system in reconstruction of the atrophic mandible
fracture. J Oral Maxillofac Surg 2004;62(6):719-723.
42. Zide MF, Ducic Y. Fibula microvascular ~ tissue reconstruction
of the severely comminuted atrophic mandible fraaure-case
report. J Craniomax~1lofac Surg 2003;31 (5) :296-298.
43. Hanson J. Lovald S, Cowgill I, et al. National hardware removal
rate assodated with internal fixation of facial fractures. J Oral
Maxillofac Surg 2011;69(4):1152-1158.
44. Papay FA. Hardy S, Morales L Jr. nFalse" migration of rigid fixation appliances in pediatric craniofacial surgery. J CranWfac Surg
19 95;6(4):309-313.
45. Yerit KC, Hainich S, Enislidis G, et al. Biodegradable fixation of
mandibular fractures in children: stability and early results. Oral
Surg Oral Med Oral Prlthol Oral Radiol Endod 2005;100(1):17-24.

46. Hardt N, Gottsauner A. 1he treatment of mandibular fractures in

children. J Craniomaxillofac Surg 1993;21(5):214-219.
47. Uckan S, Bayram B, Kecik D, et al. Effeas of titanium plate fixation on mandibular growth in a rabbit model. J Oral Ma:dllofac
Surg 2009;67(2):318-322.
48. Serena-Gomez E, Passeri lA. Complications of mandible
fraaures related to substance abuse. J Oral Max~11ofac Surg
2008;66(10):2028-2034.
49. Biller JA. Pletcher SD, Goldberg AN, et al. Complications
and the time to repair of mandible fractures. Laryngos~
2005;115(5):769-772.
50. Ellis E III, McFadden D, Simon P. et al. Surgical complications
with open treatment of mandibular rondylar process fraaures.
J Oral Maxillofoc Surg 2000;58(9):950-958.
51. Duan DH, Zhang Y. A clinical investigation on disc displacement
in sagittal fraaure of the mandibular rondyle and its assodation with TMJ ankylosis development. Int J Oral Maxillofoc Surg
2011;40(2):134-138.
52. Lo J. Cheung LK. Endoscopic-assisted rigid fixation of rondylar fraaure: a technical note. J Oral Max~11ofac Surg 2006;64(9):
1443-1446.
53. Bregagnolo LA. Bertelli PF, Ribeiro MC, et al. Evaluation of in
vitro resistance of titanium and resorbable (poly-L-DL-laaic
add) fixation systems on the mandibular angle fraaure. Int J Oral
Maxillofac Surg 2011;40(3):316-321.
54. Bhatt K, Roycltoudhury A. Bhutia 0, et al. Equivalence randomized rontrolled trial of bioresorbable versus titanium miniplates in treatment of mandibular fraaure: a pilot study. J Oral
Maxillofac Surg 2010;68(8):1842-1848.
55. Runyan CM, Jones DC, Bove KE, et al. Porcine allograft mandible
revitalization using autologous adipose-derived stem cclls, bone
morphogenetic protein-2, and periosteum. Plast Reconstr Surg
2010;125(5):1372-1382.
56. Wlkesjo UM, Xiropaidis AV. Qahash M, et al. Bone formation at
recombinant human bone morphogenetic protein-2-wated titanium implants in the posterior mandible (Type II bone) in dogs.
JOin PeriodontDI2008;35(11):985-991.
57. Zakhary K, Motakis D, Hamdy RH, et al. Effect of rerombinant
human bone morphogenetic protein 7 on bone density during
distraaion osteogenesis of the rabbit mandible. J Owlaryngol
2005;34(6 ):407-414.
58. Islam AA. Rasubala Yoshikawa H, et al. Healing of fraaures
in osteoporotic rat mandible shown by the expression of bone
morphogenetic protein-2 and tumour necrosis faaor-alpha.
Br J Oral MaxiUofac Surg 2005;43(5):383-391.

r..

Brendan C. Stack Jr

Francis P. Ruggiero

ANATOMY

Maxilla

Buttresses

The maxilla consists of paired bones also called maxillae. Each has a hollow body that is the maxillary antrum.
Projections from the maxillary body extend superiorly and
medially to the frontal and nasal bones, and laterally to
the zygoma. The inferior and medial palatine process of
the maxilla forms the bulk of the primary hard palate. The
alveolar process of the maxilla extends inferiorly and holds
the roots of the upper teeth (4).
The bone of the maxilla is for the most part quite thin.
The lateral wall of the maxillary antrum however includes
a wedge of thicker, compact bone. It is in this area that the
ZM buttress arises. It appears that the greatest occlusal load
is borne by this buttress.

The structure of the midfacial skeleton is related to its

mechanical adaptation to forces generated by mastication. Forces of up to 200 pounds per square inch are
developed during chewing. Additionally fadal contours
result from paranasal sinus pneumatization. These
sinuses are involved in voice resonance,. act as shock
absorbers, and account for an approximate lightening of
the head of 1 kg if they have otherwise been solid bone.
The concept of buttresses describes the relatively stronger
areas of the midfacial skeleton that bear the bulk of the
vertically oriented forces produced during mastication.
These forces are absorbed and transmitted to the base of
skull (Fig. 81.1) (1).
The vertical buttress system has seven components,
including three paired pillars and one unpaired structure: (a) The nasomaxillary (NM) (aka medial, nasafrontal) buttresses extend from the anterior maxillary
alveolus along the pyriform aperture and medial orbit,
through the nasal and lacrimal bones to the frontal
bone. (b) The zygomaticomaxillary (ZM) (aka lateral) buttresses extend from the lateral maxillary alveolus along
the lateral maxilla to the malar eminence of the zygoma,
then superiorly along the lateral orbital rim to the frontal bone. (c) The pterygoma~llary buttresses extend posteriorly from the maxilla to the pterygoid plates of the
sphenoid bone. (d) A midline buttress, consisting of the
vomer and perpendicular plate of the ethmoid bone,
connects the palatine process of the maxilla to the frontal bone (2).
The mostly curved, vertical buttresses are reinforced by
a number of horizontal buttresses. These include the frontal bar (superior orbital rims plus the frontal bone), the
inferior orbital rims, and the maxillary alveolus, among
others (3).

Zygoma
The zygoma is a relatively sturdy bone that is important
structurally, as an integral component of the buttress
system, and also forms the aesthetically vital malar prominence. It is related to the surrounding fadal bones via articulations with four bones-the frontal, maxillary, temporal,
and sphenoid bones.
The superficial projections of the zygoma define two
critical external arcs offacial contour (Fig. 81.2). The vertical arc follows the course of the ZM buttress (concave),
running from the zygomatic process of the frontal bone,
over the zygoma itself to the lateral antral wall of the maxilla (convex). The horizontal convex arc runs from the
maxilla in the area of the lacrimal fossa,. across the zygoma,
to the zygomatic process of the temporal bone. The point
of intersection of the vertical and horizontal arcs defines
the location of the malar prominence.
The deep projections of the zygoma are the sphenoid
projection, which articulates along the lateral orbital wall
with the orbital plate of the sphenoid bone, and the orbital
floor projection, that articulates with the orbital surface

1209

1210

Section V: Trauma

Figure 81.1 Vertical butti'Qsses of the facial skeleton: The NM

(medial), ZM (lateral), and pterygornaxlllary buttresses of the fadal
skeleton are Illustrated.

of the maxilla along the lateral aspect of the orbital floor.

The zygoma therefore constitutes the majority of the lateral
orbital rim and wall, and a portion of the inferior rim and
the orbital Boor.

PATHOPHYSIOLOGY/MECHANISM
OF TRAUMA
With the midfadal skeleton adapted to the vertical forces
of mastication, it is the force delivered at other vectoiS
that cause the bulk of midface fractures. Common etiologies of midfacial fractures include motor vehicle accidents,
assaultB, and sporting events (5).

Maxilla
i.e Fort Fractures
Rene Le Fort introduced a classification of midfacial fractures on the basis of cadaver experiments he performed in
the early part of the 20th century ( 6). He noted that fractures tend to occur at characteristic locations, which correspond with relatively weak areas of the facial skeleton.

Figure 81.2 Vertical and horizontal projections of the zygoma.

Their intersection defines the location of the malar prominence.

Le Fort Level I fractures are transverse fractures separating the maxilluy alveolus from the rest of the midfadal
skeleton (Fig. 81.3).
These injuries generally result from anterior force
directed at the lower midface. The NM and ZM buttresses
are disrupted (7). The fracture line then extends ttansversely tluough the maxillary sinus and nasal septum and
posteriorly across the pyramidal process of the palatine
bone and pterygoid processes of the sphenoid bone (2).
Le Fort l.efeJ. n fractures aeate a pyramidal NM fragment
separate from the upper craniofacial skeleton. They result
from either direct anterior force against the midface or infurior impact at the mandibular symphysis transmitted to the
midface via the dentoalveolar segments of the mandible.
Once again the NM and ZM buuresses are disrupted. this
time more superiorly than the Le Forti! I level. The fracture
line extends from the nasal root via the laaimal bone and
medial orbital wall, then anteriorly along the omital floor to
the infraomital omal. From this point the fracture line follows the ZM suture to antcrolateml I118Jillaxy wall. Posteriorly;
the fracture line passes across the infratemporal sw:face of the
maxilla through the lowerptaygoid plates (7,8).
Le Fort Left~ III fractures, which result in complete
separation of facial skeleton from the skull base. are less
common. They usually result from anterior force directed
obliquely to the plane of the vertical buttresses {1). The
vm.ical buttresses are disrupted at their superiormost
extent. 1he fracture line extends through the root of the
nose. across the lacrimal bone and medial orbital wall,
across the orbital floor to the inferior Oibital fissure. From
this point. one fracture line tmverses the lateral omital wall
as it approaches the frontozygomatic suture; a second line
passes over the back of the maxilla to the lower pterygoid
plates. An additional fracture line tluough the zygomatic
arch completes the craniofacial dysjunction (8,7).
In clinical practice. the patterns of maxillary fractures
encountered are rarely as orderly as the above suggests. U:
Fort's original wol'k demonstrates that he was certainly not
unaware of this. 1he level I to III classification scheme is
a distillation of some of his most significant experimental
observations. In his aperimentB, and most definitely in
real-life trauma. force is delivered unevenly to each side of
the face. at varying angles, and at variable locations. The
resulting fractures may be asymmetric from one side of the
face to the other (i.e., Le Fort II on the left, I.e Fort III on the
right), may combine with other fractures to aeate a more
complex pattern (e.g., aLe Fort II fracture and a zygomaticomaxillaxy complex (ZM.C) fracture on the same side of the
face constituting a complex LeFort III fracture), or may be
maxillaxy fract.ures not described by the classification at all
Other Maxillary Fractures
Anterior fon::es localized between the nose and malar
prominence may produce anterior maxillary wall fractures. Significant force delivered to the lower anterior midface. in addition to genemting the classic fracture patterns
described by U: Fort may less commonly cause fractures

Chapter 81: Midface Fractures

1211

Figure 81.3 Anterior view of facial skeletons. Shaded areas correspond to Le Fort levels I, II, and
Ill fractures. Life.ART image copyright (c) {2012) Lippincott Williams 8t Wilkins. All rights reserved.

of the palate. While they may occur in isolation. palatal

fractures tend to accompany extensive facial injuries (9).
Most often. the palate is fracwred in a sagittal fashion. in
a paramedian plane (see Fig. 81.11). Fractures in a number
of other orientations and locations are also possible (10).
Clinical indicators of palatal fractures include palatal lacerations, lip lacerations that extend into the gingivolabial
sul01s, maxillary tooth loss, and malocclusion.
Palatal fractures, and in particular those oriented sagittally, alter the width of the maxilla and permit the rotation of the maxillary dentoalveolar segment!. One of the
fundamentals in management of severe facial fracture!~ is
the inttaoperative restoration of normal maxillomandibular occlusion. with anatomic reduction of fractures following from this basis. Palatal fractures, by complicating the
restoration of occlusion, can confound this sttategy if not
appropriately addressed :first (10,11).

terms "zygomatico-orbital fracture" and "orbitozygomatic

fracture stress that because it forms portions of the lateral and inferior o:rbit. fractures that involve the zygoma
are necessarily also o:rbital fractures. The most important
point for the surgeon-in-training to undemand is that all
of the terms refer to the same injw:y. Henceforth within
this chap~ the term ZMC fracture is used for uniformity.
ZMC fractures generally result from blunt trauma to the
malar eminence, the most prominent feature of the lateral
midface. They are the second most common facial fracwre.
after nasal fractures (18). Routinely, they involve disruption of the projections of the zygoma The severity of ZMC
fractures seems most related to the force and velocity of
impact (14). In the most severe injuries, the sturdy zygoma
itself may be fractured.

Zygoma
Zygomaticomaxillary Complex Fractures
Various terms are used to describe fractures involving the
zygoma and its articulating bones. These include malar
fractures (12), zygoma or zygomatic fractures (13), ZMC
fractures (14), tripod fractures (15), tetrapod fractures,
trimalar fractures, zygomatico-Oibital fractures ( 16), and
orbitozygomatic fractures ( 17). All of these terms emphasize certain salient features of this type of injury. For example, the term tripod" underscores the obseiVation that
blunt force to the zygoma tends to disrupt not the zygoma
itsel but rathet its three superficial articulations, to the
frontal, maxillary, and temporal bones; the intact body of
the zygoma has a tripod-like appearance {Fig. 81.4). The

Figure 81.4 ZMC frac:ture-ZMC fracture, lllustratfng the tripod

lllc.e appearanc:a of the displaced :eygoma, as well as the orbital
Involvement In the Injury.

1212

Section V: Trauma

A distinctive clinical feature of ZMC fracture~ ia orbital

injuries that differ somewhat from those found in isolated o:rbital trauma. In a typical o:rbital Boor blowout
fracture, orbital volume expands; the extent of expamion
predicts the likelihood of enophthalmos and diplopia,
and the need for surgical repair. In ZMC fractures, the typical inward and medial displacement of the zygoma often
results in a decrease in o:rbital volume (19). Therefore, acute
enophthalmos ia rarely seen at the time of preaentation of
a ZMC fracture. The need for :floor exploration/repair in
ZMC fractures must also take into accoWlt the effect that
reduction will have on o:rbital volume
.Another common clinical feature of ZMC fractures is
facial numbness and paresthesia. This is caused by damage
to the infraorbital nerve {V2) at its exit &om the midportion of the inferior orbital rim, which lies directly within
one of the fracture lines. These symptoms are present in
as many as 90% of ZMC fracture patients at presentation
(20). The symptoms resolve spontaneously in many, but
not alL patients after disimpaction of the fragments.
Zygomatic Arch Fractui'VS

1he zygomatic arch is most frequently disrupted as a component of a ZMC fracture (21). Less common, and distinct
from this type of injury, is the isolated zygomatic arch fracture. Isolated arch fractures result &om a direct lateral force
to the arch. most frequently the result of a motor vehicle
accident or fisticuffB (21 ).
Several fracture patterns may be seen in iaolated arch
injuries. 'Ihe most common pattern is two mobile fragments of arch resulting from a total of three fracwres. In
this pattern, the fragments are displaced medially. in a
v configuration (Fig. 81.5).

Figu,. 81.6 Patient who suffered an isolated fracture of the left

zygomatic arch after direct blow from a batted softball. Depression
of the lateral midface is quite visible in this case.

Patients with isolated arch injuries, particularly those with

the characteristic v pattern. will have a palpable, and frequently visible, deformity of the lateral midface (Fig. 81.6).
This :finding is often accompanied by a degree of trismus,
resulting from the impingement of the fraCIJ.lre segments on
the underlying coronoid process of the mandible or the temporalis muscle.

PATIENT EVALUATION
Evaluation of the patient is the critical first step to assure
complete and accurate fracture repair and optimal aesthetic results. There may be a temptation to truncate the
physical exam, in deference to the almost universal use
of admission pan computerized tomography (CI') for
trauma patients. Although high-resolution cr has been
a great advance in the diagnosis, treatment, and postoperative critical evaluation of facial trauma, imaging is
not a substitute to the laying on of hands in a focused
head and neck trauma evaluation. Poor aesthetic results
should not be accepted in facial fracture repair, as the
primary motivation for their repair in many cases is
cosmesis.

Physical Exam

Figure 81.5 Axial bone-window CT de~monmates the most common pattwn of lsol~rted frac:t:ui'Qs of the zygomatic arch: a total of
three fractures create two fragme~nts, displaced me~dlally In a -like
conflguratfon.

Regardless of the existence of scans, or the putative diagnosis offered by the consulting physician, each new facial
trauma patient should be evaluated in a systematic fashion, beginning with the history and physical exam.
All facial trauma patients are trauma patients, and
are best served by the standardized Advanced 'D'auma Life
Support (ATLS) approach taught by the American College of
Surgeons. '!his evaluation process ensures the orderly evaluation and prioritization of treatment of the most lethal injuries first. All residents and those practicing surgeons who
manage facial trauma must be familiar with the trauma

Chapter 81: Midface Fractures

evaluation process, and should consider certification in

AJLS. We shall highlight portions of the trauma evalua-

tion process that are particularly germane to the care of the

maxillofacial trauma patient.
Airway issues can potentially be seen with any head
and neck trauma sufficient to result in midface fractures.
While isolated midfacial trauma is unlikely to compromise the airway, accompanying mandible fractures are
particularly significant in this regard. A loss of continuity
of the mandible arch results in retrusion of the tongue
and larynx, which may create an obstructed upper airway.
When evaluating such a patient, consideration should be
given both to immediate need for airway management
and its implications for fracture repair. If elective intubation (as opposed to an emergent airway) is possible,
alternatives to oral intubation should be entertained if
maxi.llomandibular fixation (MMF) will be required for
fracture repair.
Concomitant C-spine injuries are also common in
patients with facial fractures, with an incidence approaching 10% (22). All facial trauma patients should thus be
managed with C-spine precautions as proscribed by AJLS,
even though this can significantly complicate the evaluation and management of the facial injuries.
Neurologic deficits should be sought and well documented if they exist Of particular pertinence in the facial
trauma patient are cranial neuropathies. A regimented
exam of cranial nerves II-XII should be performed.
Findings of significance that may impact the timing and
approach to repair include neuropathies affecting the eye
(cranial nerves II, III, IV, and VI), the trigeminal nerve. and
the facial nerve.
Eye-related cranial neuropathies might make surgery
an emergency; especially if associated with an open globe.
Conversely, the presence of a compromised optic nerve
(optic neuropathy) may delay facial fracture management
More details of the ophthalmologic evaluation of facial
trauma patients are presented below.
Trigeminal nerve injury is not an emergency per se but
must be documented preoperatively. If not, the assumption is made that it was a surgical complication and this
has been a point of litigation specifically related to facial
fracture repair. Facial nerve dysfunction is usually related
to a temporal bone fracture or extensive facial soft tissue
injury. It is important to know if the nerve was functioning
upon presentation or not. This will help with the decision
to explore and perhaps repair the nerve immediately or to
treat expectantly.

The Facial Assessment

There are key elements of the exam that must be appreciated and documented preoperatively. These elements will
help the surgeon appreciate the full extent of the facial
trauma as well as avoid problems with litigation that is a
potential element in trauma cases.

1213

The appearance of the face is examined. Is it wide or

long? Is it asymmetrical? It is helpful but often difficult to
obtain current pretrauma photos to assist with this assessment. Appreciation of any lacerations is important for
planning surgical access as well as to focus exam for cranial
nerve deficits. A full facial movement and sensory examination is also advised regardless of hard or soft tissue injury.
Overlying edema and patient discomfort may limit the
utility of palpation. Still, palpation of the facial skeleton
is mandatory. and can provide a more thorough understanding of the location of fractures and the extent of their
displacement and mobility. A bimanual exam of the face
should be performed. Placing gloved fingers in the mouth
while stabilizing the head and face at various levels is
used to examine for dentoalveolar and palatal stability, as
well for the Le Fort fractures. Both visual and subjective
(patient's report) occlusal changes are vital to obtaining
a successful reduction of facial fractures. Finally, are there
exposed fracture elements and what is the status of the soft
tissue? Will there be adequate soft tissue for reduction and
closure of the fracture?

The Ophthalmologic Evaluation

The ophthalmologic exam of facial trauma patients deserves
special emphasis and should never be deleted. Ocular injury
is common in the facial trauma patient. at the time of initial
injury, during the course of surgical repai.J; and even postoperatively. These injuries may be particularly devastating for
patient and surgeon alike.
Early and complete ophthalmologic evaluation of every
patient who has sustained a ZMC fracture (or any fracture
involving the orbit) is an ideal yet often unrealized goal.
The incidence of major (potentially blinding) ocular injury
in ZMC fractures that require repair has been reported as
10% (23). Reconstructive surgeons must be sensitive to the
possibility of direct ocular trauma and obtain consultation
as indicated. A minimal preoperative examination includes
testing of visual acuity (subjective and objective in both
eyes), pupillary function, and ocular motility; inspection
of the anterior chamber for hyphema; and visualization of
the fundus for gross disruption. The presence of an afferent pupillary defect should be specifically sought, as this is
a sensitive indicator of the presence of optic neuropathy.
A decrease in visual acuity, alteration in color perception,
or any abnormality observed on the other portions of this
screening examination warrants detailed examination by
an ophthalmologist before reconstruction of the bony
injuries is undertaken.

COMPUTED TOMOGRAPHY
Evaluation of a patient with midface trauma has been
greatly improved by the use of high-resolution cr. One
millimeter slice thickness has become standard in many
institutions, allowing for excellent coronal and sagittal

1214

Section V: Trauma

lD

DIAGNOSIS/EVALUATION

CT scan is the "workhorse" imaging study for the evaluation of

miclfacial trauma.
Review offacial CT scan should include the status of the buttress system, zygomatic arches, orbital volume, and herniation
of orbital contents.
Direct coronal imaging for orbital floor and skull base imaging.
Newer reformatting software of thin axial slice images offers
high-quality image and avoids cervical extension.
Sagittal imaging can facilitate orbital trauma evaluation.
Postoperative CT imaging can document anatomic reduction.
Basic evaluation of visual function (and documentation thereof)
should precede operative management.
CT, computed tomography.

reconstructions. lhis modality is the ..work horse for

evaluation of midface trauma. Axial and coronal scans
identify fracture lines throughout the entire facial skeleton
(Table 81.1 ). The expense of Cf evaluation of patients with
facial fractures other than simple nasal and mandibular
fractures appears justified and can be done in virtually all
emergency rooms (24).
Using the Cf images, the buttress system, particularly the
vertical struts, must be systematically inspected preoperatively to document the degree of malalignment because of
fracture fragment displacement. Fracture lines themselves
through the buttresses do not mandate open reduction,
but comminution, gross malalignment, and instability on
physical exam all strongly suggest the need for reduction
of the fractures in order to restore facial length and projection. Computed tomographic scans can show fractures of
the condylar head, condylar neck. and vertical ramus of the
mandible. The status of these structures must be known
before fracture dislocations of the maxilla are placed into
occlusion with the mandible.
The arcs of contour of the zygoma (see Fig. 81.2) are
evaluated for decisions about the need for surgery and the
appropriate operative approach. The cr finding of comminution and dislocation of both ends of the horizontal arc
of contour indicates that exact reconstruction of the orbitozygomatic complex will be a challenge, and consideration
should be given to additional access incisions, including an
open approach to the zygomatic arch via a coronal incision.

FRACTURE MANAGEMENT: PRINCIPLES

Immediate Reconstruction
The goal of modern fracture management is acute neartotal or total initial reconstruction of the bony architecture
of the injured facial skeleton (Table 81.2). Early reconstruction usually is less difficult and more successful than
delayed reconstruction, mainly because the latter can be

[9 TREATMENT
Early repair of miclface fractures prevents soft tissue contracture
that can be difficult to normalize in a delayed approach .
Meticulous attention to soft tissue closure and facial soft
tissue red raping is essential to achieving a pretraumatic facial
appearance.
Anatomic reduction prior to plate fixation is key. Rigidly fixated,
malreduced structures will result in a persistent facial deformity
requiring revision surgery.

complicated by cicatricial contraction of the facial soft tissues if the underlying skeletal support collapses or is lost.
During the acute phase of injury, the soft tissues are pliable
enough to allow restoration of the underlying bony configurations with local bone fragments or autogenous bone
grafts. If the soft tissues are allowed to contract into a bone
defect, restoration of the soft tissue to a normal position by
delayed restoration of the supporting bone invariably produces a less desirable result. If revision surgery for minor
residual bone defects or lacerations is required, it is greatly
facilitated if the overall soft tissue envelope has been maintained in a normal position by a previous anatomic reduction of the facial skeleton.

Maxillomandibular Fixation
MMF maintains an important role in the management of
midfacial trauma. In palatal and Le Fort fractures, as well as
more complex pan-facial injuries, the relationship between
the maxilla and the upper craniofacial structures is frequently altered and always destabilized. Placing the patient
into occlusion (MMF) restores the position of the maxilla
in the horizontal plane if the mandible is intact and correctly related to the skull base-that is, properly seated in
the glenoid fossa. However, it does not automatically reestablish midfacial height if the vertical buttresses have been
disrupted by fracture dislocations.
In most midface cases, MMF is used intraoperatively, as a
guide to maxillary positioning, and then released at the
end of the case. While closed reduction and MMF for 4 to
6 weeks are adequate management of less complex. minimally displaced maxillary fractures, patient discomfort and
inconvenience rarely support this approach. Additionally.
long-term immobilization of the temporomandibular
joint (TMJ) (greater than 4 weeks) places the joint at jeopardy for developing an arthropathy. Early TMJ movement
and physiotherapy are ideal. The vast majority of maxillary
fractures are best managed by means of open approaches,
with direct visualization and anatomic reconstruction of
the buttress system with plating. Sometimes in pan-facial
injuries, a period of postoperative MMF is appropriate as a
stabilizing adjunct

Chapter 81: Midface Fractures

MMF can be accomplished with directly bonded orthodontic brackets applied before open reduction and
fracture-line plating. This method reduces the risk of arch
bar wiring and can reduce operative time. Other innovations in MMF, which reduce surgeon risk and decrease
operative time include four-point screw fixation when
tooth-bearing structures are intact and/or rapid plastic zip
tie fixation with laced dental chain elastics (25-28).

Approaches
Extended access approaches expose the facial skeleton
widely without compromising the facial soft tissue with
visible scars. These approaches (coronal, transconjunctival, buccogingival, midfacial degloving. etc.) allow direct
visualization and accurate reduction of fracture displacements. The zygoma and all of its projections, including the zygomatic arch, and all walls of the orbit can be
safely and almost totally exposed through a combination
of incisions, which if properly executed, should be either
hidden completely or barely perceptible. The lower ends
of the vertical buttresses can be exposed through extended
sublabial incisions that essentially deg]ove the maxilla.
Although this frequently removes all residual external
periosteal attachments to displaced maxillary fracture fragments, bony union should proceed in a timely manner if
the fragments are adequately stabilized and the periosteum
is redraped over them. When extended access approaches
are used, care should be taken to dose them meticulously
with attention to periosteal closure. soft tissue resuspension, hemostasis, and wound drainage.
The choice of approaches for a particular patient and
a particular injury relies not only on the technical expertise to execute a variety of incisions well, but also wisdom,
experience. and judgment. On the one hand, a surgeon
may be hesitant to perform extended access approaches
in favor of more limited approaches in the hope that any
facial asymmetry resulting from incomplete fracture reduction will be imperceptible. However, the range of imperceptible asymmetry is small, and the surgeon cannot rely
on it to hide suboptimal results from nonanatomic reductions that might have been improved with more extensive
exposure and reconstruction. The classic clinical example
is an incompletely reduced zygoma with unilateral facial
widening. On the other hand, because these wide access
approaches exist it does not mean that they are always
indicated. The fact that incisions are hidden does not mean
they are completely free of sequelae and the risk of complications. Experienced surgeons obtain excellent results
with the judicious use of more ..minimalist.. approaches
to some injuries, such as dosed reduction or single incision access to ZMC fractures (29). The increasing use of
endoscopes, surgical navigation systems, and intraoperative imaging is likely to facilitate selective use of limited
access approaches to facial trauma without compromising
accurate reduction.

1215

Stable Internal Fixation

Although the term rigid is used to describe the fixation
achieved with plating systems, it is somewhat overstated
when applied to midface fractures. Rigidity sufficient to
allow removal of MMF can be obtained, but it is not always
sufficient to allow the patient to return immediately to a
normal diet. Fixation devices do maintain the position of
the maxillary dentoalveolar complex: under the stresses
of forces generated by mastication of soft foods, speech,
and deglutition. They will preserve the anatomic reduction
achieved and allow for bone healing.

FRACTURE MANAGEMENT: SURGICAL

TECHNIQUES
Zygomaticomaxillary Complex Fradures
The goals of ZMC fracture repair are (a) restoration of the
normal facial width and projection at the malar prominence, (b) restoration of normal orbital volume, and (c)
achievement of the first two goals while eliminating, or at
least limiting. the sequelae and complications associated
with the operative repair itself. These are the considerations the surgeon managing a ZMC fracture must have in
mind as he or she considers the options-in terms of incisions used, methods of reduction, and the number, type,
and configuration of plates.
The incisions typically employed for ZMC repair are
shown in Table 81.3. Each incision offers access to one or
more of the articulations of the zygoma, at a variable cost
in terms of the residual scar and the other attendant soft
tissue changes. Access to articulations serves two purposes:
(a) a means to confirm the alignment of reduced fragments
visually and (b) the ability to plate the area to stabilize the
reduction. Choice of incisions varies significantly based
on the severity of displacement and comminution, surgeon preference. and other factors. On some principles,
there is considerable agreement-for instance, the subciliary incision has fallen into general disfavor because of the
relatively high risk of ectropion and lid shortening with it
in comparison to the other incisions (subtarsal, transconjunctival) that expose the same anatomy (17).
A related issue is the decision regarding how many
articulations, and which ones, to expose. Each articulation
site has differing value for (a) confirming the alignment
of reduction and (b) bearing the hardware required to stabilize reduction. For example, the sphenozygomatic (SZ)
articulation within the lateral orbit is generally regarded
as best single place to assess the accuracy of reduction
(17,30-32). Conversely, the ZM and zygomaticofrontal
(ZF) sutures, with their relatively thick bone stock along
the load-bearing ZM buttress, are the most favorable sites
for plate fixation (33). Table 81.4 describes the relative values for each purpose for each articulation, along with an
estimate of the accessibility of the suture, in light of soft
tissue cost of approaching it.

1216

Section V: Trauma

INCISIONS USED IN MANAGING ZMC FRACTURES

Incision

Pros

Cons

Exposed for
Alignment

Exposed for
Plating/Repair

Gingivobuc:c:al sulc:us

No visible sc:ar
Only ac:c:ess for floor
exploration/ repair
No c:antholysis needed
to access ZF suture
Excellent exposure of lateral
orbit; only practical
exposure of arc:h

ZM buttress
infraorbital rim
Infraorbital rim ZF
suture ZS suture
ZF suture ZS suture

ZM buttress

Lower eyelid subc:iliary

subtarsal transc:onjunctival
Upper eyelid lateral brow
upper blepharoplasty
Coronal

Oral flora
c:onta minati on
Risk: of ectropion,
sc:leral show, etc:.
Visible sc:ar

Infraorbital rim ZF
suture orbital floor
ZF suture

Risk:s of widened sc:ar,

facial nerve branch
weakness, and
temporal hollowing

Arc:h ZF suture ZS suture

Arch ZF suture

In light of the potential sequelae and complications of

surgery, some consideration must be given to not repairing
non- or minimally displaced ZMC fractures (30). When this
plan is chose~ patients should be followed for at least a few
weeks to confirm that further displacement doesn't develop
as a result of masseter muscle actio~ and that no unsuspected deformity becomes apparent as edema resolves.
Displaced fractures are generally repaired. Some groups
have advocated the use of closed reduction techniques
without any plating (34,35) in their efforts to eliminate
the soft tissue consequences of repair. However, it has been
demonstrated in at least one small study (36) that this
approach is significantly inferior to open reduction internal
fixation (ORIF) in terms of the accuracy of reduction; use of
this should be limited to carefully selected cases.
The use of a single incision and a single point of fixation, either an upper eyelid incision and plating of the ZF
suture ( 3 7, 15) or an upper gingivobuccal sulcus (GBS)
incision and plating of the ZM buttress (38), have yielded
favorable results for some. More typically, three or more
articulations are exposed, and at least two are plated.
One reasonable approach to the displaced ZMC fracture, and that favored by the authors, begins with a GBS
incision. Through this, the ZM suture and infraorbital rim
suture are both exposed. An initial attempt at reduction is

then carried out through the same incision, by inserting an

elevator under the body of the zygoma and elevating and
rotating it toward a reduced position. In some cases, generally those with no comminution, this results in perfect
reduction, and the reduction can then be stabilized with
a single, appropriately contoured L-shaped plate along the
ZMsuture.
More commonly, reduction is incomplete or uncertain
at this point, and a second incision is made. The second
incision may be a lower lid incision, such as the transconjunctival or subtarsal incision, which allows access to the
infraorbital rim, the SZ suture, and with a lateral crease
extension and lateral canthotomyfcantholysis, the ZF
suture as well. The lower lid incision is facilitated by the
partial reduction of the zygoma carried out through the
GBS incision; placing the transconjunctival incision properly over a displaced orbital rim is difficult. Another option
for the second incision is the lateral portion of an upper
blepharoplasty incision, through which the ZF suture and
SZ suture (but not the infraorbital rim) may be exposed for
inspection and plating.
Through this additional access, the reduction is further fine-tuned and confirmed. Plating on the ZM suture,
the infraorbital rim, and/ or the ZF suture are then carried
out, while the reduction is maintained with the elevator.

ARTICULATlONS WHICH MAY BE EXPOSED FOR MANAGING

ZMC FRACTURES
Articulation

Stability

Alignment

Accessibility

Zygom aticofronta I
Arch
Infraorbital rim
Zygom aticosphen oid
ZM

++
++
+
a

+
+
+
+++

++
+
++
+

+++

++

+++

Although it has been described as a particularly stable plating position by some authors (Rohner 2002;
others), many authorities mnsider the ZS suture quite difficult to access for plating (AO).

Chapter 81: Midface Fractures

1217

Orbital ftoor exploration is carried out at thia point if indicated (see disrussion below). The repair is completed by
soft tissue resuspension over the degloved maxilla. 1he
Wldmurfac:e of the malar soft tissue is sutured with one
or more abso:rbable stitches to a stable superior structure,.
such as a plate or intact periosteum. If a cantholysis has
been performed. canthotom:y is performed at this point
Finally, the mucosal and skin incisions are closed.

Other Issues in ZMC Fracture Repair

Methods of Reduction
1here are a number of options for the method of reduction
of the displaced zygoma. The authors find that in most
cases, the introduction of an elevator under the body of the
zygoma through the GBS incision provides adequate control of the zygoma to achieve reduction. Other methods,
including use of percutaneous hook {34,37), introduction of the elevator through a separate incision such as the
Gillies incision (36), and the use of a Carol-Girard screw
(33) are usually WlDece:ssar:y, but should be kept in mind
for particularly difficult reductions, or if the GBS incision
is not being used.

Figure 81.7 The location, shape, and siZQ of some of the plates
commonly used In the ORIF of ZMC fract:ures. (a) ZF sut:ure: a thin
(1.3 equivalent}, linear mldfac:a plate. Alternatively, a box-shaped
plat may be used for enhanced stability. (b) Infraorbital rim: a very
1hln (1.0 equivalent), gently curved, mldfaa~ plate. (c) ZM sut:ure:
an Intermediate to thick (1.5-2.0 equivalent), Lshaped plate.

Hardware
In the past. midfac:e plating systems consisted of progressively thicker plates paired with progressively larger diameter screws, with the screw diameter used as the identifying
measurement and a proxy for the thidmess and rigidity of
the plate. That is, a "2.0"' system would comprise a relatively
thick and rigid plate and a 2-mm diameter screw, a 1.o
system would consist of a 1-mm diameter screw paired
with a thin and more malleable miniplate. and "1.3' and
"1.5" systems would occupy intermediate positions. This
taxonomy is obsolete now, as most of the hardware manufacturm offer systems in which a single diameter screw
is used with all thidmesses of plate. or sevf!l'al plate thicknesses are available for a given screw size. Nevertheless, all
manufacwrers continue to offer an array of systems with
different thiclmesses and rigidity within their midfac:e sets.
Haxdware is chosen for a particular site based primarily on:
(a) the load to be borne by that site and (b) the amount of
soft tissue coverage awilable to camouflage the plate. For
example,. the ZM buttress, which bears a significant load
during mastication and is covered by a generous soft tissue
envelope,. is generally plated with a larger (i.e., the plates
formerly lmown as 1.5 and 2.0), L-shaped, midface plate.
Figure 81.7 offers a schematic representation of typical
hardware deployment in ZMC fracture repair.

Orbital Floor Management in ZMC Fractures

Prior to the widespread application of cr scans in ZMC

fractures, the orbital floor was &equendy explored via the

same lower lid incision used to repair the ZMC (39). With
the routine use of preoperative cr scans in these injuries
have come fairly standardized clinical and radiographic

criteria for o:rbital ftoor exploration. These include entrapment of orbital soft tissue,. herniation ofsoft tissue into the
maxillat:y sinus, and 2 cm2 or greater of o:rbital floor disruption. This has reduced the need for ..diagnostic' ftoor
exploration in many ZMC patients, reducing the rate of
ftoor exploration to 30% to 40% (39,40).
The o:rbital floor injw:y associated with ZMC fractures
is distinct &om that seen in isolated o:rbital injuries, such
as "blowout" fraelllres. In blowout fractures, the orbit
volume is almost uniformly increased. In ZM.C fractures,
the posterior-medial displacement of the zygoma often
causes a decrease in oifrital volume. This has promulgated
the theoretic concern that reduction of the zygoma anterolaterally could increase o:rbital volume,. perhaps above
the threshold where postoperative enophthalmos might
ensue. This issue has been addressed is several excellent
recent studies (19,39,40). In each study, the suspicion
that reduction of the zygoma might lead to orbital volume
expansion beyond that seen of the preoperative imaging
was confirmed; howevet it was also shown consistendy
that in nearly every patient. the expansion was not clinically significant-that is, unlikely to expose patients to an
increased risk of enophthalmos.
With this in mind, it is dear that the o:rbital ftoor in
ZMC fractures may be managed selectively, using criteria
for exploration similar to those in use for other orbital
ftoor fractures. Many swgeons have taken advantage of
this fact by avoiding lower lid incisions entirely in some
of their ZMC patients in f.lvor of say, a combined GBS and
upper blepharoplasty incision. This spares the patient &om
the risk of scleral show and ectropion.

1218

Section V: Trauma

B
Figure 81.8 A: Preoperative allial bone-window CT demonstrates a right ZMC fracture with mild
external rotation and medial displac:Bment of Ute arch. The patient had moderate trismus. 1: Post
reduction CT ofthe same patient. Fracture repair was performed through a GBS incision and a transconjunctival incision, with plating of the ZM buttre" (not shown} and infraorbital rim (white atTow}.
The zygomatic arch alignment has been restored (black arrow) without being directly visualized or
addressed, simply by reducing the zygoma through the GBS incision.

'!he technical details of o:rbital floor repair are similar

to those in blowout fractures, which are covered extensively in Chapter 82 of this ten. Needless to say, in patienu

where floor repair is indicated, this is carried out after the

ZMC reduction and plating.
The above discussion is most applicable to the typical,
isolated ZMC fracture that results &om low to midenergy
trauma. High.-eneJgy injuries, those with greater displacement and/or comminution, and those found in the setting
of pan-facial injuries require a more aggressive approach.
Consideration should be given to the exposure of additional fracture sites, including the zygomatic arch. This
allows additional points of reference to confirm anatomic
reduction and the placement of other plates to enhance
stability. Another factor that favoiS additional exposure is
less experience on the part of the swgeon (33).
In summary, repair of ZMC fractures offen the surgeon
many options. An effective approach to management carefully balances the benefits of exposure, for alignment, plating, and orbital floor repail;. with the cost in terms of soft
tissue sequelae and potential complications inCUITed by
each incision. As long as this balance is respected, e:x:ceUent
results can be achieved in a variety of ways.

or intraoral (Keen) approach may be necessary to realign

the arch. It is an uncommon event that the arch component
of a ZMC fracture needs to be directly visualized and plated
(13). These exceptional cases would typically be in the setting of high.-energy injuries or pan-facial trauma.
Isolated arch fractures, especially those with the characteristic V configuration, are amenable to closed reduction
by the method described by Gillies (42).In this technique,
a small incision is made in a hair-bearing portion of the
temporal scalp (F'tg. 81.9). Dissection is canied down
through the fascia of the temporalis muscle. A blWlt instrument can be safely passed in this plane, deep to the frontal

Zygomatic Arch Fractures

In arch fractures that are a component of a ZMC fracwre,
reduction of the zygoma frequently results in satisfactory
reduction of the arch (41) (Fig. 81.8).
In some 01Ses, after reduction and plating of the zygoma,
a closed reduction of the arch via a Gillies (described below)

Figure 81.9 Plaoament of the lndslon Gillies approach to Isolated zygomatic arch fractures. The Incision may also be orlerru~d
transversely or obliquely-the patient's hair provides exa~llent
camouflage.

Chapter 81: Midface Fractures

Figure 81.10 lndslonal scar from Gillies approach to the zygomllt:lc arch 11t 2 weeks. Even IJt this Q&rly stage, In a patient 'llllfth

short hair, the scar Is bal'lilly peroaptlble.

branch of the facial neiVe, and underneath the arch. While

palpating the fracture with one hand, the instrument is
elevated with othe:t effecting reduction. The reduced fragments, particularly those in a v-shaped arch fracture, are
usually stable in the reduced position. In imtances when
they are not. several transcutaneous sutures may be used to
suspend the fragments from a plate or finger splint affixed
to the area. Other methods of temporarily supporting the
reduction have also been described (43).
The advantages of the Gillies technique for zygomatic
an:h. fracture repair include an imperceptible incisional scar
(F'tg. 81.10); minimal disruption of the sensitive soft tissue
structures adjacent to the zygomatic arch, meaning very little risk of frontal branch injw:y or temporal hollowing; its
simplicity; and the possibility of performing the procedure
with local anesthetic. with or even without sedation.

Palate
The integrity of a fractured palate must be reestablished in
oroer to establish a stable occlusion. Palatal fractures, most
commonlyp;uasagittal splits, can be reduced anteriorly at the
infurior rim of the pirifoim aperlllre. Occasionally, the need
for stability mandates plate placement posteriorly on the
oral surface of the palate to allow a solid, structurally accurate dentoalveolar complex. to be related to the mandibular
teeth (see below). Open reduction and internal fixation of
the anterior extent of a palatal fracture can be accomplished
through the same extended gingivobuccal sulcus incision
used to expose and repair thevmial buttresses of the face.

1219

The bone above the anterior teeth is more than adequate

for placement of a miniadaptation plate with multiple
monocorti.cal screws. In some imtances, a small amount
of bone can be removed immediately below the anterior
nasal spine to facilitate placement of a plate with a flat contour under the upper lip and base of the columella. Care
to prevent tooth root injuries should be exercised. This can
be achieved both by placing the plate above the root tips,
using monocortical screws, and ensuring screw holes are
placed in the tooth root inteispaces.
The posterior alent of a palatal fracture usually can be
reduced in a closed manner if the overlying palatal muc~
periosteum is intact. Difficulty can result from an inability
to align the lower end of the ZM butttess with an accurately
recomttucted zygoma above. Also the need to avatighten
the MMP wires to pull the lingual cusp tips of the maxillar:y
molars and premolars into the central fossae of the mandibular teeth can be problematic. In these ases, an incision
can be made aver the posterior extent of the palatal fracture.
and a transosseous wire or small plate can be placed across
the fracture. This wire does not ser:ve as a point of rigid fixation of the palatal fracture, but it reduces the fracture gap
posteriorly after it is tightened. Stable :fixation is obtained
with superlidal triangulation of the palate with plates and
screws placed across the anterior extent of the palatal fracture and across both ZM buttress areas (Fig. 81.11).
Transoral palatal plates are often difficult to cover with
mucosa. These plates can be placed transmucosally and
removed once fraelllres have healed. Posterior distraction of a parasagittal palatal fracture can be overlooked
easily if a parnsymphyseal mandibular fracture is present
that has been incompletely reduced at the lingual cortex.
Both dental an:hes are widened posteriorly, and the maxillary and mandibular teeth can appear to interdigitate correctly. Howevet when facial edema resolves, the patient

r}
(
Denotes application of

fixation device

Fracturv closed in posterior palate with wire

Figure 81.11 Reducdon of the posterior gap In a displaced paraSIJglttal frac:tui'IOI of the palate using a transosseous wire. Arrows
lndla.rt:& the location of plates that a !'Iii points of triangular fixation
that hold the fractuna In reducdon.

1220

Section V: Trauma

may notice widening of the intagonial distance and have a

wcheekyappeatance
Palatal ftacwres exposed by means of laceration of the
mUCDperiosteum usually are widely separated and impossible to reduce without a ttansosseous wire to pull the palatal shelves together posteriorly. If this method of reduction
is not used. and tightening of the MMF wires only is used
to pull the teeth into occlusion, the maxillary teeth probably will be lingually tipped or left in some degree of unilateral or bilateral posterior crossbite deformity. 1he exposure
through the laceration may be adequate to allow placement of a plate across the split palate; howev~ this procedure can be technically difficult, and these plates frequently
become exposed in the mouth and must be removed.
Aaylic palatal splints are essential adjWlcts for stabilization of teeth in a segment of maxillary bone separated
from the palate by an alveolar fracture. Even if a rigid :fixation device cannot be used to attach the isolated alveolar
segment to the surroWlding maxillary bone, the combination of a sturdy buccal arch b~ a palatal splint. and circumdental wires to dnch the involved teeth between the
bar and the splint usually provides enough stability to
allow removal of the MMF at the end of the case.

Maxilla
Restoration of the pretrauma relationships of the toothbearing segments of the maxilla to the mandible and skull
base necessitates reestablishment of the proper occlusal

relation of the maxillary and mandibular teeth and stabilization of the midfadal buttress system (Fig. 81.12). If
the mandible also is fractured. the lower dental arch must
first be stabilized and accurately related to the skull base;
proper alignment of the mandibular condyles in the glenoid fossae is an absolute requirement 1he anteroposterior position of the maxilla can be established by means of
occluding the teeth in stable MME 1he midfadal vertical
dimension is established by means of reduction and fixation of all fracture lines between the palatoalveolar complex and the base of the skull. When subcondylar fractures
or fractures of the condylar head cannot or should not
be managed with open reduction, the midfadal buttress
system can be reconstructed :first to establish vertical and
horizontal positioning of the occlusal plane. 1his alternati~ approach may not restore the relation of the maxilla
to the base of the skull with the same accuracy that can be
achieved if it is first related to an intact or totally reconstructed lower dental arch. This sequence, however, is the
preferred sequence if mandibular vertical ramus height
cannot be accurately restored because of the presence of
posterior mandible fractures or comminution.
Although not a part of the maxilla, each zygoma must be
acrurately repositioned and stabilized before reattachment of
the maxilla to the upper ends ofvertical but:aresses. Zygomatic
fractures associated with I.e Fort f'ractures of the middle
third of the facial skeleton often necessitate open reduction
and internal fixation of the zygomatic arch. to position the

CT Evaluation
Axial

Coronal

1
Venical bullresses
noncomminuted.
minimally displaced

Venical buttresses
comminled, displaced

Mandible nol intacl ___.... Condylar head or high

condylar neck fraclures

~
Closed reduction. MMF

Mandible imac1

Low condylar neck,

vertical ramus, body,
or symphaseal fractures

~
OR, RfF vertical
Buuress if 4--Q weeks
of MMF unacceptable
to patient

l
1

OR, Rlf vertical buttresses

MMF

MMF

OR. RIF mandible

MMF -------,

1l
TMJs undislllrbed,
passive MMF obtained

OR, RIF any other

mandible fractures

l.

MMF as JOdJcated for

treatment of condylar head

or high neck fractures

TMJs injured (although not fracwred),

or MMF used 10 "pull into occlusion"

OR, RIF vertical

buttressesl

OR, wire fixation of buttresses

Remove MMF, allow

immediale function

4-6 weeks of MMF

Figure 81.12 Algorithm for the managemtilnt of fractures of the vertical buttresses.

Chapter 81: Midface Fractures

zygoma correctly before reattachment of the maxilla 1his is

partirularly critical if mandibular condylar fractures necessitate reconstruction of the upper jaw first. Failure to recognize
and correct the amount and direction of displacement at the
time of reduction leaves a flattened cheek and widened face
and can produce a rotation and tilting of the maxilla when it
is reattached to a malpositioned zygoma.
Only after the zygomatic and palatal fractures have been
repaired can the maxillary complex be reattached superiorly.
Reattachment begins with the ZM buttress that has the less
severe injury. Unlike the anterior wall of the maxilla, which
often is severely comminuted, the ZM buttress often is traversed by a single fracture line that can be easily reduced, or
it has a single free-floating fragment that can be accurately
related to the zygoma above and the lower maxilla below.
At least one ZM buttress usually can be reduced in this way
to set the correct vertical dimension of the middle third of
the face. After stabilization of this buttress, reduction and
fixation of the other ZM buttress and the NM buttresses can
proceed. If both ZM buttresses are severely comminuted,
reconstruction of the NM buttresses can facilitate reestablishment of the vertical dimension. In most cases of comminution of the ZM struts, however; the NM buttresses are
even more fragmented and difficult to realign.
Stability of the reattached maxillary complex is gained
mainly through reconstruction of the ZM buttresses.
Reconstruction of the NM buttresses can provide some
supplementary vertical stability to the overall reconstruction, but only if the upper confluence of these struts ( nasoorbitoethmoidal complex) is intact. If plates and screws
are used for fixation and the patient is allowed to function
early. a delicate nasoorbitoethmoidal repair cannot be
relied on to transmit occlusal forces to the base of the skull.
Instead, ZM buttress reconstruction must be used to hold
the repositioned maxilla in place during healing. Plates
must be positioned to overlie the ZM buttresses as closely
as possible. and three screws are used to anchor the plate
to the zygoma above and the maxilla below. Placement of
screws into the lower end of a plate or a bone graft can be
difficult if the fracture line closely parallels the apices of
the molar and premolar teeth. This problem usually can
be overcome with L-shaped plates that allow placement of
more screws close to (often in between) but not through
the root tips.
Comminution of the lower ends of the vertical buttresses severe enough to mandate bone grafting for adequate stabilization is uncommon, although occasional
cases occur in which gaps of 1 to 2 em of severely comminuted or absent bone exist in one or both lateral antral
walls. Onlay split cranial bone grafts are attached across
these gaps. The grafts can be contoured and positioned to
allow placement of lag screws that do not damage the root
tips. Reconstruction of the vertical dimension cannot be
done with the same precision for these patients as for those
who undergo successful edge-to-edge approximation of in
situ fracture fragments.

1221

COMPLICATIONS AND SEQUELAE

Perhaps the most common complication of midface fractures
is inadequate reduction resulting in facial deformity, and in
some cases, functional deformity (see below).1his complication represents a technical error at the time of surgery.

Eye/Eyelid/Orbital Complications
Eye-related complications are common in midface
trauma (especially in ZMC fractures) and include lower
eyelid injury, including ectropion, entropion, and most
commonly, scleral show; enophthalmos, with or without diplopia; corneal abrasion; and visual loss (rare).
One way that many surgeons are preventing lower lid
sequelae of midface trauma is by simply choosing not
to make lower lid incisions when possible; for instance,
in patients with ZMC fractures who do not require floor
exploration, an upper blepharoplasty incision access to
the FZ suture is chosen over the lower lid approach to the
infraorbital rim. This approach essentially eliminates the
risk of scleral show and other lower lid issues, otherwise
quite common even with a well-executed transconjunctival incision.
In other respects, the eye, eyelid, and orbital complications of midface trauma mirror those seen in isolated orbital
fractures, and are covered in greater detail in Chapter 82.

Lip Distortion
A subtle but disturbing deformity can be caused by use
of the sublabial approach to maxillary fractures. This
deformity includes hollowing of the soft tissue contours
over the canine fossa area and superior deviation of the
comer of the mouth and lateral aspect of the upper lip.
It is caused by collapse and contraction of the buccal soft
tissues into large anterior and anterolateral antral wall
defects. Although the exact size of the defect necessary to
cause this is unknown, defects of greater than 1.0 cm2 are
considered for overlay bone grafting.

Implant-Related Complications
Miniplates and screws along the lateral orbital rim (ZF
suture) and zygomatic arch usually are visually undetectable if low-profile (1.3 mm equivalent) titanium or
cobalt-chromium alloy plates with are used. These fixation devices can be left in place permanently. Inferior
rim plates are those that most likely produce an irregular
contour visible through the thin skin of the lower eyelid.
Prevention of this complication is critical because if such
a plate is placed and is visible after healing is complete, a
second surgical violation of this lower lid to remove the
plate exposes the patient to a higher risk for lid complication. Options include the use of very low-profile (1.0 mm
equivalent) hardware; wire, rather than plate, fixation of

1222

Section V: Trauma

the infraorbital rim; placement of the plate along the superior surface, rather than the anterior face, of the rim; and
avoidance of rim fixation altogether by choosing the ZF
suture as a second point of fixation.
Generous soft tissue coverage makes plate visibility
along the ZM and NM buttresses extremely uncommon.
Intraoral plate exposure does occur in these areas however,
as well as on the palate; this can be managed expectantly in
most cases, or with plate removal after bony union. Finally,
plate and screw failure, such as is seen in mandibular fractures, is uncommon in midface trauma.

Malocclusion
While malreduction in ZMC fractures causes cosmetic issues
such as facial widening and malar flattening, the same
errors, when applied to Le Fort and palatal fractures, will
have significant functional consequences. Rigid fixation is
an unforgiving technique that produces serious occlusal
disturbances if used inappropriately to manage fractures
of tooth-bearing segments. If the plates are not correctly
adapted to the bone, tightening of the screws can produce torque in the system, and the fragments can be distracted so that malocclusion is produced when the MMF
is removed. This is less likely to occur now that thinner,
more malleable titanium or cobalt-chromium alloy plates
are being used rather than the stiffer, harder to bend stainless steel plates.
The surgeon must consider the risk of inaccurate condylar seating in the glenoid fossae in all cases involving
tooth-bearing segments of bone. Patients with complex
maxillary injuries can have a deranged occlusal relation
that is difficult to correct and prevents the teeth from
interdigitating in a passive manner before application of
MMF. One or both mandibular condylar heads invariably
are displaced from their normal centric occlusion position in the glenoid fossae if the MMF is used to pull the
patient into occlusion." Even if the plates are subsequently
and accurately adapted to the repositioned maxillary fragments, malocclusion develops after MMF is removed and
the patient's normal muscle balances return the mandible
to its correct position. If gross malocclusion does not result
and the patient learns to function in this altered position,
chronic TMJ discomfort is likely to develop.
When postoperative occlusion is noted, the only successful form of remediation is revision surgery. including
revision of the reduction and fixation. Simply reapplying
MMF in the hope that the patient's muscles or orthodontic
traction bands will pull the patient into occlusion is uniformly unsuccessful because of the rigidity of the fixation
devices.

Sensory Disturbances
Numbness and paresthesias in the distribution of the
infraorbital nerve (V2) are common in midface fractures,

owing to the frequent involvement of the infraorbital

canal and foramen within the fracture lines. In many
patients, these symptoms resolve with or without treatment. In patients in whom they persist, they can be significant source of annoyance, particularly when eating
(44). The impact that fracture management has on these
symptoms is uncertain. Clearly, careful dissection around
the nerve when exposing the maxilla through the GBS is
advisable. Some studies suggest a salutary effect of operative repair on nerve recovery (45), while some authorities specifically advise against operative management to
decompress" the infraoroital nerve in the absence of
other surgical indications (18).

Other Complications/Sequelae
Facial nerve injury, particularly to the frontal branch. may
result if a coronal approach to the zygomatic arch is performed. Temporal hollowing due to atrophy of the temporal
fat pad is a more common sequela of the coronal approach.
Despite the transoral placement of implants, infectious
complications of midface fractures are unusual (46).

TECHNICAL ADJUVANTS
Surgical Models and Computer-Aided Surgery
Although most information necessary to evaluate midface fractures can be seen on standard axial and coronal
cr scans, three-dimensional reconstructions can help surgeons better conceptualize the overall injury. Precise calculation of displacement of superficial bony landmarks
is possible with three-dimensional images (47,48). This
is particularly valuable for patients who cannot be positioned for true coronal cr for optimal evaluation of the
oroital walls. However, coronal reformations generated
from fine-cut axial cr scans are less expensive and more
readily obtained than three-dimensional reconstructions.
Although they do not supply the same detail in equal
clarity, the coronal reformations usually supply adequate
information.
Additional technologic enhancements to aid the surgeon in repair of complex facial trauma include sagittal Cf
reconstruction for oroital floor fractures (49), computeraided surgery navigation for facial fragment reduction
(50,51 ), and preoperative computer-generated models for
surgical planning. particularly helpful for reconstruction in
the delayed setting and revision cases (52).

Intraoperative CT Scanning
Portable cr scanners allow immediate radiographic
evaluation of fracture reduction in the operating room
(53,54). The quality of these scans appears sufficient to
allow evaluation of relocation of the malar prominence
on axial scans and realignment of the orbital walls on

Chapter 81: Midface Fractures

coronal reformations. This technology facilitates the

use of closed reductio~ single incisio~ endoscopic
approaches, and other "minimalist" approaches to midface fracture repair by confirming the reduction of unexposed fractures. This spares the patient the soft tissue
sequelae associated with multiple incisions and periosteal stripping. Furthermore, the expense of the scanner
and technologist time can be offset by elimination of the
need for extended access approaches to evaluate reduction of each fracture line, thus decreasing operating room
time and expense.

Although reduction of the displaced zygoma in

ZMC fractures may cause an increase in the orbital
volume relative to that seen on the preoperative
imaging, the amount of the increase is rarely clinically significant. Therefore, the orbital floor components of ZMC fractures can generally be managed
according to the same principles applied to isolated
orbital floor fractures.
MMF serves as a very useful guide to the proper relationship between the maxillary dentition and the
skull base in the horizontal plane. This relationship
loses validity. and the patient is at risk of postoperative malocclusio~ if the mandibular condyles are
not seated properly in the glenoid fossa at the time
the patient is placed into occlusion.
Injuries to the eye and C-spine are common in
midface fractures and patients must be carefully
evaluated for these injuries. Preoperative visual evaluation is mandatory. and ophthalmologic consultation should be strongly considered, for all patients
being brought to the operating room for repair of
midface fractures involving the orbit.
Intraoperative imaging and surgical navigation are
two newer technologies that may in the future facilitate less invasive approaches to midface fractures
without compromising accuracy of repair.
Palatal fractures tend to occur in the setting of multiple other facial fractures. Palatal fractures must be
addressed early in the sequence of repairing these
injuries, in order to allow the use of the patient's
occlusion as a guide to the accurate reduction of the
other fractures.
There is a wide array of successful strategies for
managing ZMC fractures. Depending on the nature
of the particular injury and the experience of the
surgeon, options may include close reduction techniques, single incision approaches with plating,
and multi-incision, wide access approaches with
plating.

1223

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26. Nikkhah C, Wright S, Thompson MK, et al. Re: Use of specialized bone screws for intermaxillary fixation. Ann Plast Surg
2001;47:93; author reply 93.

1224

Section V: Trauma

27. McCaul JA, Devlin MF, Lowe T. A new method fur temporary
maxilla-mandibular fixation. IntI Oral MaxiUofac Su'X 2004;33:
502-503.
28. Pigadas N, Whitley S, Avery CM. Temporary intermaxillary
fixation and cross infection control. Br I Oral Maxillofac Surg
2003;41:363.
29. Bezuhly M, Lalonde J. Alqahtani M, et al. Gillies elevation and
percutaneous Kirschner wire fixation in the treatment of simple
zygoma fractures: long-term quantitative outcomes. Plast Rewrutr
SUIX 2008;121:948-955.
30. Evans BG, Evans GR. MOC-PSSM CME article: zygomatic fractures. Plast Rewrutr SU~X 2008; 121:1-11.
31. Kelley P, Hopper R. Gruss J. Evaluation and treatment of zygomatic fractures. Plast Reconstr SU~X 2007;120:5S-15S.
32. Rohner D, Thy A, Meng CS, et al. lhe sphenozygomatic suture
as a key site fur osteosynthesis of the orbitozygomatic complex
in panfacial fractures: a biomechanical study in human cadavers based on clinical practice. Plast Rewrutr Surg 2002;110:14631471; disrussion 1472-1465.
33. Carl-Peter Cornelius NG, S0re11 Hillerup, Kenji Kusumoto,
Warren Schubert. AO Surgery Reference - Midface. Available at:
http:/fwww2.aofoundation.orgfwpsfportalf!utfp/cl/04_SB8K8x
LLM9MSSzPy8xBz9CPOos3hng7BARydDRwMLlyBXAyMvYz8zE
wNPQwN3A30j_zcVP2CbEdFADw8CUE!fdl2fd1/L2dJQSEvU
Ut3QS9ZQnB3LzZfQzBWUUFCMUEwOEVSRrAySjNONjQwST
EwRzA!f?showPage=diagnosis&bone=CMF&segment=Overview
&showCMF=true. Accessed 5/23/2011 2011.
34. Bissada E, Chacra ZA, Ahmarani C, et al. Orbitozygomatic complex fracture reduction under local anesthesia and light oral sedation. J Oral Maxs1lofac Su'X 2008;66: 13 78-1382.
35. af Geijerstam B, Hultman G, Bergstrom J, et al. Zygomatic fractures managed by closed miuction: an analysis with postoperative computed tomography follow-up evaluating the degree
of reduction and remaining dislocation. I Oral MaXJ1lofac Surg
2008;66:2302-2307.
36. Czerwinski M. Martin M, Lee C. Quantitative comparison of
open reduction and internal fixation versus the Gillies method
in the treatment of orbitozygomatic complex fractures. Plast
Rewrutr SU~X 2005; 115: 1848-1854.
37. Kovics AF. Ghahremani M. Minimization of zygomatic complex
fracture treatment. Inti Oral Maxillofac Su'X 2001;30:380-383.
38. Fujioka M. Yamanoto T, Miyazato 0, Nishimura G. Stability of
one-plate fixation for zygomatic bone fracture. Plast Reconstr Surg
2002; 109:817-818.
39. Ellis E. Status of the internal orbit after reduction of zygomaticomaxillary complex fractures. J Oral Ma~llofac Surg 2004;62:
275-283.
40. Czerwinski M. Izadpanah A, Ma S, et al. Quantitative analysis
of the orbital floor defect after zygoma fracture repair. J Oral
Maxillofac Su'X 2008;66:1869-1874.

41. Stewart MG. Zygomatic complex fractures. In: Stewart MG,

ed. Head, face, and neck trauma. New York: Thieme Medical
Publishers, 2005:68-76.
42. Gillies HD, Kilner T, Stone D. Fractures of the malar-zygoma
rom pound with a description of a new x-ray position. Brit I Surg
1927;14:651-656.
43. Chin SH, Chicarilli ZN, Narayan D. Alloderm stabilization of
zygomatic arrlt fractures. I Craniofac Su'X 2006;17:403-404.
44. Kurita M. Okazaki M, Ozaki M. et al. Patient satisfaction after
open mluction and internal fixation ofzygomatic bone fractures.
I Craniofac SUIX 2010;21 :45-49.
45. Sakavicius D, Juodzbalys G, Kubilius R. et al. Investigation of
infraorbital nerve injury fullowing zygomaticomaxillary romplex
fractures. I Oral Rehabil2008;35:903-916.
46. Andreasen JO, Jensen SS, Schwartz 0, et al. A systematic review of
prophylactic antibiotics in the surgical treatment of maxillofacial
fractures. I Oral Maxillofac SUIX 2006;64:1664-1668.
47. Ploder 0, Klug C, Voracek M, et al. A computer-based method
for calrulation of orbital floor fractures from coronal romputed
tomography scans. I Oral MaXJ1lofac SUIX 2001;59:1437 -1442.
48. Ploder 0, Klug C, BackfriederW, et al. 2D- and 3D-based measurements of orbital floor fractures from cr scans. J Craniomaxillofac
SUIX 2002;30:153-159.
49. Rake PA, Rake SA, Swift JQ. et al. A single reformatted oblique
sagittal view as an adjunct to roronal computed tomography for
the evaluation of orbital floor fractures. I Oral Maxillofac Su'X
2004;62:456-459.
50. Kokoska MS, Hardeman S, Stack BC, et al. Computer-aided
reduction of zygomatic fractures. A1t'h Facial Plast Surg 2003;5:
434-436.
51. Pham AM, Rafii AA, Metzger MC, et al. Computer modeling and
intraoperative navigation in maxillofacial surgery. Otolaryngol
Head Neck Su'X 2007;137:624-631.
52. Cao D, Yu Chai G, et al. Application of EH compound artiiicial
bone material combined with computerized three-illmensional
reconstruction in craniomaxillofacial surgery. J Craniofac Surg
2010;21 :440-443.
53. Hoelzle E Klein M, Schwerdtner 0, et al. Intraoperative computed tomography with the mobile Cf Thmoscan M during
surgical treatment of orbital fractures. Int J Oral MaXJ1lofac Su'X
2001;30:26-31.
54. Pohlenz P, Blake E Blessmann M, et al. Intraoperative cone-beam
romputed tomography in oral and maxillofacial surgery using
a Carm prototype: first clinical experiences after treatment of
zygomaticomaxillary romplex fractures. J Oral Maxillofac SUIX
2009;67:515-521.

z.

Clinton D. Humphrey

OVERVIEW
Orbital fractures occur both as isolated injuries and in
conjunction with additional maxillofacial fractures or multisystem trauma. Patients with an orbital injury require
initial evaluation by the emergency department (ED) physician and in some cases activation of the trauma team
following current Advanced Trauma Life Support (ATLS)
protocols (see Chapter 74). The identification of orbital
fractures during the initial ED workup should lead to a
request for facial trauma surgeon consultation. Computed
tomography (cr) scanning is standard for confirming or
identifying fractures. Fractures of the zygomaticomaxillary complex (ZMC), orbital rim, medial orbital wall, and
orbital floor are most commonly encountered. Fractures of
the superior orbit occur less frequently and are often associated with frontal sinus fractures and intracranial involvement. Naso-orbital-ethmoid (NOE) fractures tend to be
associated with complex midfacial and maxillary trauma
(see Chapter 81). The management of NOE fractures differ from the management of most orbital fractures and is
discussed in detail elsewhere. The surgeon's prompt evaluation of orbital fractures is indicated once life-tlueatening
injuries have been addressed and the patient is stabilized.
Ophthalmology consultation is appropriate in selected
cases (1). Certain indications and ideal timing for orbital
fracture repair remain controversial. Surgical intervention
should restore preinjury appearance and function.

ANATOMY
The orbital skeleton contains contributions from the frontal, sphenoid, lacrimal, ethmoid, maxillary, zygomatic,
and palatine bones. The supraorbital rims are entirely
comprised of the frontal bone. Laterally, the frontal bone
articulates with the zygoma. More posteriorly, within the
orbit, the zygoma also articulates with the greater wing of

J. David Kriet

the sphenoid. Portions of both the zygoma and maxilla

make up the infraorbital rim and, along with a small contribution from the palatine bone. the orbital floor. The
medial orbit is a complex confluence of the ethmoid lamina papyracea, lacrimal bone. maxilla, and nasal process of
the frontal bone. The bony orbit and locations of the optic
foramen, ethmoid artery foramina, and orbital fissures are
shown in Figure 82.1A. Moving posteriorly, the anterior
ethmoid artery, posterior ethmoid artery, and optic nerve
are located approximately 24, 36, and 42 mm, respectively
from the anterior lacrimal crest Figure 82.2B. Upper and
lower eyelid layers are detailed in Figure 82.2 (2).
The lateral canthal tendon consists of two limbs. A thin
anterior limb blends with the orbicularis oculi muscle
fibers and periosteum of the lateral orbital rim; a thicker
posterior limb attaches to Whitnall tubercle of the zygoma.
The medial canthal tendon attaches via two limbs as well.
A thicker limb extends to the anterior lacrimal crest and
a thinner limb containing Homer muscle to the posterior
lacrimal crest. Intimately related to the medial canthal tendon is the lacrimal system. Upper and lower puncta begin
5 to 7 mm lateral to the canthus and continue as a common canaliculus into the lacrimal sac located between the
anterior and posterior limbs of the medial canthal tendon
within the lacrimal fossa. The sac empties into the inferior
meatus via the nasolacrimal duct. Figure 82.3 demonstrates
the complex relationship between the lacrimal drainage
apparatus and the medial canthal tendon. The lacrimal
gland is located along the superolateral orbit within the
upper lid and divided into a larger orbital portion and a
smaller palpebral portion by the lateral hom of the levator aponeurosis. Anteriorly, the gland's orbital portion is in
contact with the orbital septum (3,4).
Extraocular muscles include the two oblique and four
rectus muscles. The course of the superior oblique muscle
brings it into nearly direct contact with the periorbita of the
orbital roof and medial wall at the trochlea. The inferior

1225

1226

Section V: Trauma

6
Figure 82.1 A: The frontal sphenoid, lacrimal, ethmoid, maxillary, zygomatic, and palatine
contributions to the orbit are shoiM'I. 1: As measured from the anterior lacrimal cnast, the anterior
ethmoid artery, posterior ethmoid artery, and optic foramina are located at 24, 36, and 42 mm, re
spectlvely. (B from Humphrey C, Krlet JO. Surgical approaches to the orbit. Operat Tech Otolaryngol
Head Neck Surg 2008;19:132-139, \'1o'ith permission).

B
Figure 82.2 Lower eyelid layers include skin, orbicularis, oculi, tarsal plate, conjunctiva, and orbital
septum {A). Upper eyelid components include skin, orbicularis oculi, levator palpebrae superioris
aponeurosis, Muller muscle, tarsal plate, conjunctiva, and orbital septum (1). C, palpebral conjunc1iva;
10, inferior oblique muscle; IR. inferior rectus muscle; lA levator palpebrae superioris aponeurosis;
MM, Muller muscle, 00, orbicularis muscle; OS, orbital septum; P, periosteumlperiorbita; TP,
tarsal plate. (From Ellis E, Zide MF.. Surgical approaches to the facial skeleton 2nd ed., Philadelphia,
PA: Lippincott Williams 8r. Wilkins 2006, with permission).

Chapter 82: Orbital Fractures

1227

Orbicularis
Periorbita

Septum

Pli<a Semilunaris
Lacrimal Lake

Lower Canaliculus

Lacrimal Fascia
Gland

~ Medial
1

Edge of
Lacrimal Sac

Periorbita
Medial Palpebral
ligament

Orbital Rim

Figure 82.3 Upper and lo\Wr puncta begin 5 to 7 mm l~~t:eral to the c:.anthus and converge to form
the common canaliculus. The common canaiiC1Jius enters the lacrimal sac thllt Is loc1Jt8d between the
anterior and pomarlor limbs of the medial canthal tendon. The pomarlor limb of the tendon contains
Horner muscle~. (From Janfaza P, Nadol JB, Galla, RJ, et al. Surgical anatomy of the head and neck,
Phlladcillphla, PA: Lippincott Williams & Wilkins 2001, wft:h permission).

oblique is in proximity to the omit at its origin just posterior

to the inkromedial Oibital rim, lateral to the superior end
of the na.solaaimal canal, and occasionally from the fascia over the laaimal sac. The superiot inferiot lateral, and
medial recws muscles originate from the annulus of Zinn.
All of the extraocular muscles insert directly onto the sclera.

DEMOGRAPHICS AND ETIOLOGY

O:rbital fractures requiring treatment commonly occur
secon.dal:y to blunt trauma incurred during violent assaults,
accidental injw:y (falls, sports injuries, work-related), or
motor vehicle accidents. While these fractures occur at any
age, young males are most often affected. The most typical injw:y patterns among all patients are isolated blow-out
fractures of the orbital :floor and fractures of the ZMC. ZMC
fracwres by definition involve the orbital :floor and lateral
orbital wall (5). Isolated trapdoor type fractures of the floor

are more common in the pediatric age group than in adults

( 6,7). O:rbital roof fractures occur with high-enetgy injuries
that often produce concomitant intracranial sequelae.

Orbital Blow-Out Fractures

lhe majority of orl>ital floor blow-out fractures occur
medial to the infrao:rbital nerve and inferior orbital fissure
with preservation of a medial strut extending posteriorly
off of the nasomaxillary buttress and adjacent to the lacrimal bone (Fig. 82.4). 1\vo wall fractures involving both
the o:rbital floor and the medial wall are less common but
must be identified preoperatively as reconstruction is exponentially more challenging, especially if the medial strut is
disrupted. In both orbital floor and medial wall fractures,
an intact posterior shelf of maxillary or palatine bone
will be preserved that must be identified for stable and
anatomic implant placement (Fig. 82.5). In medial wall

1228

Section V: Trauma
the lilrelihood of developing enophthalmos or persistent
diplopia (8,9). Purtha;. any classification system based
on radiologic :findings alone is unlikely to reliably predict
these sequelae and the need for surgical intf!IVention.

Zygomaticomaxillary Complex Fractures

fractures, there is usually a stable superior shelf of frontal

bone above the level of the anterior and posterior ethmoid
arteries. These arteries indicate to the sw:geon the level of
the cribriform plate and skull base
Yano et al presented a simple classification system
for blow-out fractures, separating them into linear,"
"punched-out,." and "burst" fractures. Linear fractures
were minimally dislocated. Punched-out and bum fractures referred to ftacwres involving respectively less than
half or more than half of the wall (orbital floor or medial)
(8). Unfol1Unately, this classification system and alternatives offered by others generally do not correlate well with

Classic mpod," or tetrapod, fractures of the ZMC

involve medial rotation of the zygoma at the arch due to
blunt trauma at the lateral aspect of the malar eminence
Significant dislocation results in disruption of the horizontal buttresses at the infraorbital rim and zygomatic arch.
The vmical zygomaticomaxillary and zygomaticofrontal
buttresses are disrupted as well. Rotation of the body of the
zygoma causes displacement along the lateral o:rbital wall
at the zygomaticofrontal and zygomaticosphen.oid suture
lines (Fig. 82.6). The o:rbital ftoor is disrupted by an extension of the o:rbital rim fracture that runs posteriorly along
the zygomaticomaxillary suture line and adjacent to the
infraorbital nerve. Infraorbital anesthesia or dysesthesia is
present in almost 25% of cases (10).
Zingg proposed a classification system that would
sttatify ZMC fractures based on concise description of the
anatomic sites involved. 'I}'pe A fractures are isolated to the
zygomatic arch. lateral o:rbital rim, or infraorbital rim alone
Type B fracttlres are classic monofragment tettapod fract:ures
as previously described that involve disruption of all four
zygomatic articulations. 'I}'pe C fractures are more complicated tetrapod ftacwres in which there is comminution of
the zygoma 1hi.s system does guide treatment somewhat
as closed reduction was appropriate for select type A and
B ZMC fractures, and open reduction was always indicated
for type C fractures in a series of over 1,000 cases ( 10).

Figure 82.5 A posterior shelf of maxillary and/or palatii"HH bone

will be presarved following an orbital blow-out fracture (large
arrow). During repair, this shelf must be Identified and used for
stable and anatomic Implant plaa~ment. Note the convex contour of
the posterior orbital Boor (asterlslc). An Implant must also replicate
this convex contour In ordclr to correctly restore orbital volume.
(Figure courtesy of Cr. Barton Branstetter).

Figure 82.6 This three-dimensional CT reconstruction dem

onstrates a classic tetrapod fracture of the ZMC resulting from
Impact at the lateral aspect of the malar eminence. The Impact
results In counterclockwlsa rotation and posterior displacement of
the zygoma. (Figure courtesy of Cr. Barton Branstetter).

Fig we 82.4 A medial strut extending pom~rlorlyfrom the vertical

nasomaxfllary buttress Is typically preserved following an orbital
blow-out fracture. This strut Is a usaful landmark for orientation
and provides a stable anteromedlal shelf for Implant placement
when attempting repair. (From Farwc~ll CG, Sires BS, Krlet JC, et al.
Endoscopic repair of orbital fractures: use or misuse of a new approach. Arch Fads/ Ptsst Surg 2007;9(6):427-433, with permission).

Chapter 82: Orbital Fractures

1229

B
Figure 82.7 Two theories are used to explain the mechanism by which orbital blow-out fractures
occur. The bone conduction theory states that force is transmlttad through an Intact Infraorbital rim
to the thinner orbital floor (A). The hydrostatic theory suggests that Impact to the globe Increases
Intraorbital pressure, causing the orbit to fract:ure at the weakest point, typically the orbital ftoor or
medial wall (B). (From Waterhouse N, Lyne J, Urdang M, et al. An Investigation Into the mechanism
of orbital blowout fractures. Br J Plast Surg 1999;52:607-612, with permission).

Orbital roof frac:tures are Wlcommon with an estimated

incidence of 1% to 9% of all facial fracwres ( 11). In adults,
they are most commonly produced as a result of a highenetgy impact such as a motor vehicle accident. In children.
fractures may occur as an mension of a linear frontobual
fracture with falls being the most common etiology. One
must maintain a high index of suspicion for intracranial
injuries manifesting as pneumocephalus, cerebrospinal
fluid (CSF) leaklJ, or encephalocele formation in patients
with orbital roof fractures (12).

A third hypothesis-a modification of the hydrostatic

theOty-proposes that it is displacement of and direct
contact of the globe with the orbital floor or medial wall
that results in the fracture. A cadaver study by Rhee et al. in
2002 provides strong support for the hydrostatic theoJ:Y by
demonstrating that increased pressure within the orbit in
the absence of rim impact results in blow-out fractures. This
study also suggested that direct contact of the deformed
globe with the orbital floor or medial wall is not required
for fradllre (15). Despite this evidence bolstering the pure
hydrostatic theory, each of these mechanisms could potentially play at least some role in the clinical setting.

Biomechanics and Pathophysiology

EVALUATION

1he pathophysiology for most facial fractures is straight-

All trauma patients should initially be stabilized and evaluated accon:ling to A11S protocol by an ED ph:y!idan or
the trauma team. Patients with sm'!l'e o:rbitofadal trauma.
decreased visual acuity, and/or double vision should be
evaluated by the facial trauma swgeon acutely and admitted to the hospital ifwarranted. Conversely, discharge from
the ED and follow-up within 3 to 5 days for outpatient
evaluation is appropriate for carefully selected patients.
Periorbital edema will decrease in the interval, making
the examination less difficult and offering an improved
assessment of potential enophthalmos. Comprehensive
screening cr scans have become increasingly common in
complex trauma cases. Identification of orbital fractures on
these screening cr scans is often the impetus for consulting the facial trauma swgeon. In the event that fracwres
are initially discovered on ph:y!ical exam or noted on plain
films or a head cr, a fine cut (less than 2 mm) maxillofacial scan with axial, coronal, and sagittal reconstructions
is indicated. Axial images are useful in evaluating medial

Orbital Roof Fractures

foJWard in that the fracture occun at the site of impact. For

ez:ample, ZMC fractures result from impact sustained at
the prominent malar eminence. Orbital blow-out fractures
occurring in the absence of an infrao:rbital rim fracture are
unique because the fracture-producing force is transmitted
indirectly. Two popular, but not mutually e:x:clusive, theories have traditionally been used to explain the mechanism
of these blow-out injuries. The first. bone conduction (or
buckling) theory, was originally described by I.e Fort (13)
and maintains that force is transmitted through the thicker
bone of the rim into the thinner bone of the Boot resulting
in a fracture of the floor but maintaining an intact rim. The
bone conduction theory does not as adequately explain
how isolated medial wall blow-out fractures might occur.
.Alternatively, the hydrostatic theoty suggests that impact
to the globe results in increued intraorbital pressure
that fractures the o:rbital Boor and/or medial wall at the
weakest points (14). Figure 82.7 illustrates both theories.

1230

Section V: Trauma

wall &actures. Coronal images provide excellent viewJ of

the orbital ftoo:~;. medial wall, and roof. Sagittal images are
helpful in assessing the position of the stable posterior
shelf. When available, three-dimensional reconstructions
are useful for gaining a broad overview of fracture patterns
and fragment orientation.
The availability of a high-quality screening cr scan
should not preclude the facial trauma specialist from
obtaining a detailed history and pf!Iforming a thorough
physical examination. The historian should inquire about
mechanism of impact. previous eye sw:ge:ry, double vision,
numbness, preinjury vision status, and use ofanticoagulant
medications or other comorbid factors. 1he physical examination begins with assessing pupillary response and visual
aarlty. The use of a pocket-sized Snellen chart is helpful
for performing an initial vision check. Most smartphones
are now able to display such a chart, making the documentation of visual aruity feasible in most circumstances.
Color perception is another useful bedside test Patients
with traumatic optic neuropathy may perceive a bright
red object (e.g., light shining through the dosed eyelid)
as a dull brown. While the facial trauma surgeon may not
have access to a slit lamp for funduscopic examination. the
anterior chamber should be inspected for the presence of
hyphema (Fig. 82.8).1f available, a Naugle ex.ophthalmometer can easily be used in the clinic to objectively determine the presence and degree of enophthalmos (Fig. 82.9).
Extraocular movements (EOMs) are assessed, observing for
symmetty and the presence of diplopia during the exam. It
is not Wlcommon to note some diplopia at the extremes of
gaze, espedally after a &acture causes substantial edema in
the affected eye The status of other cranial nerva, particularly the facial and trigeminal, is determined. Anesthesia or
dysesthesia in the distribution of the in&aorbital branch of
the trigeminal frequently occurs in association with o:rbital
&actures. Likewise, paresis in the buccal branch of the facial
nerve can be seen. It is imperative that any neural deficits
be documented preoperatively. 1he combined :findings
of neurologic injwy and an upper eyelid hematoma in a

Figure 82.9 A Naugle exophthalmomcn:er can be used to

objectively measure enophthalmos. This exophthalmometer Is
stabilized on the supraorbital and Infraorbital rims.

child should raise suspicion for the less common o:rbital

roof &acture (16).1he zygomatic arches, zygomaticofrontal
sutures, in&ao:rbital rims, and nasal bones are palpated for
tenderness or step-of&. The zygomaticomaxillary buttresses
are most effectively palpated intraorally. Occlusion and
mi.dface stability are also sautinized.
Indications for ophthalmologic evaluation in patients
with o:rbital fractures remain controversial. Some advocate for an immediate and comprehensive ophthalmologic evaluation of every patient with an o:rbital fracture.
In many institutions, this is difficult to achieve and
probably unnecessary. At a minimum, it is advisable
that the facial trauma surgeon document EOM, pupillary response, and an objective exam of visual acuity
prior to any surgical intervention. A prospective study by
Grant ( 17) has demonstrated that up to 30% of patients
with orbital fractures have significant ocular injury
that could lead to at least partial loss of vision if undiagnosed. Another study by Mellema et al. on the incidence of ocular injuries in patients with orbital &actures
demonstrated that severe ocular injuries are extremely
uncommon when patients are visually asymptomatic.
Surprisingly, changes in visual acuity alone are a poor
predictor of ocular injury. Pain, double vision, flashes of
light (photopsias), blind spots (scotomata), and floaters are more sensitive indicators. The presence of any of
these symptoms including changes in visual acuity is a
dear indication for immediate consultation of an ophthalmologist (1).

INDICATIONS FOR SURGICAL

MANAGEMENT

Figure 82.8 VIsible hyphema (blood In the anterior chamber of

the eye) shown In a patient. Hyphema Is most fn~quently cauHd
by blunt trauma. (Photograph courtesy of Michael P. Grant, MD.)

Many o:rbital &actures require inter:\lention to return the

patient to preinjwy appeamnce and functional status.
Modem approaches are safe and aesthetically acceptable
when perfonned properly. Selerting the most appropriate surgical approach will optimize exposure and increase

Chapter 82: Orbital Fractures

the lilrelihood of sucassful treattnent Most orbital fractures do not require wgent intervention and can be repaired
within 2 weeb. Resolving soft tissue mayWlcoverenophthalmos and allow transient diplopia to resolve {18). Decreased
swelling also facilitates improved surgical exposure. If any
orular injury is suspected, we obtain ophthalmology consultation after complex orbital trauma prior to surgical
intervention. Evidence ofhyphema, ocular rupture, or other
globe injwy should delay internal orbital approaches until
an ophthalmologist can address the injwy (19).

Orbital Blow-Out Fractures

U~gent

treatment of orbital blow-out fracwres is prudent

in a select group of fracture patients. Though possible in
adults, it is most often children who develop the closed
trap door or "white-eyed" fracture that traps periorbital
tissues and frequently the inferior rectus muscle (20).
ProfoWld entrapment and, rarely, the oculocardiac reflex
(OCR) ensue. Even if the OCR is not present. these fractures should be repaired early to prevent irreversible damage to the incarcerated and ischemic inferior rectus muscle.
Indications and ideal timing for repair of more routine
isolated orbital :floor and medial wall blow-out fractures
are unclear in many ciralmstances. Certainly patients
with diplopia secondary to entrapment on the basis of
physical examination (positive forced dudion testing) or
radiologic evidence merit exploration and repair within
2 weeks (18,21). Likewise, enophthalmos that develops
immediately after a blow-out fracture will not improve and
is likely to worsen without surgical intervention. Swgical
candidacy of patients lacking early functional deficits is a
greater dilemma. 'Iladitionally, a cr demonstrating a fracture that involves at least 50% or 2 cm 2 of the Boor and/
or medial wall has been an indication for repair to prevent
late enophthalmos. PronoWlced roWlding of the inferior
rectus muscle is also used to identify patients who will
benefit from swgery. Rounding of the inferior rectus with
a height-to-width ratio greater than or equal to 1.00 on
coronal cr scan is predidift of late enophthalmos development (22). Greater than 2 mm of soft tissue prolapse
into the maxillary or ethmoid sinus is another proposed
indication (5,23). Obsemng patients with less extensive
fractures for 3 weeks or mare may help to identify those
who do not meet the aforementioned thresholds or criteria
but will still develop enophthalmos. Patients in this category can be repaired in a delayed fashion and still have
excellent outcomes (24).

1231

exposure, anatomic reduction, and intemal fixation. The

most complex. cases require a coronal approach to rees.
tablish the contour of a comminuted zygomatic arch. The
swgeon should consider intervention for patients with rotation andfor displacement of the body of the zygoma more
than a few millimeters. Facial asymmetty will often be perceptible later if a displaced ZMC fracture is left untreated.
Though ZM.C fractures involve the orbital Boor, orbital
Boor exploration and repair is not indicated for all patients
with ZMC fractures. Ellis reported that patients with preseiVed orbital contour did not receive orbital exploration at
the time of ZMC repair and did not experience long-term
sequelae from their orbital injuries. On the other hand,
patients with one of the following two criteria were more
likely to benefit from surgical exploration of the orbital
Boor while repairing the ZMC fracture: (a) comminution
of the internal orbit sufficient to change orbital shape,
increasing the volume of the bony orbit,. and (b) significant prolapse of orbital soft tissues into the maxillary and/
or ethmoid sinuses through the displaced fracture of the
orbital Boor even when it is not comminuted (5).

Orbital Roof Fractures

Since the majority of orbital roof fractures are non- or
minimally displaced. they are often managed expectantly.
Exceptions are blow-in fractures (Fig. 82.10) resulting in
exophthalmos, levator dysfunction, or superior rectus
entrapment (12). Growing linear fractures requiring repair

Zygomaticomaxillary Complex Fractures

ZMC fracture repair is indicated whenever significant dis.
placement occurs. The least invasive approach to achieve
stable anatomic fracture reduction should be utilized.
In select cases, a dosed reduction alone is adequate. In
many cases, multiple open approaches are required for

Figure 82.10 Orbital roof blow-In fracturQS are rare but can
result In exophthalmos, levator dysfunction, and/or superior rectus
entrapment. (Figure courtesy of Dr. Barton Branstetter).

1232

Section V: Trauma

are reported in children (25). Late complications sudt as

encephaloc:de formation are sometimes dted as indications
to uniformly intervene and repair orl>ital roof fracwres.
Encephaloc:des do not occur routinely, and, if they do
develop, delayed surgical management is dfuctive (12,26).

SURGICAL TECHNIQUE
For orl>ital fractures requiring treatment, adequate exposure
fadlitates successful repair. A variety ofsurgical approadtes
will be described that can be used individually combined
gain access to any area of the orbit Once exposed, ZMC
and orbital rim fractures are reduced and if necessar:y stabilized with low-profile titanium scraw and miniplates.
Blow-out defects can be successfully repaired with a variety
of autogenous and alloplastic materials. While autologous
materials, sudt as cranial bone grafts, were used extensively in the past. the majority of swgeons have switdted
to alloplastic materials for their ease in use and predictability (i.e., no potential for resorption) (23,27). Popular
alloplasts include titanium mesh, porous polyethylene. or
composite titanium mesh-porous polyethylene implants
(28-30). Titanium mesh plates preformed to simulate the
three-dimensional anatomy of the entire orbital floor and
medial wall have become available in recent years. These
plates are particularly useful for anatomic reconstruction
of combined blow-out injuries to these areas. A common
error when using any material to replace missing portions
of the orl>ital floor or medial wall is inadequate restoration
of the convexity that is present posteromedially (Fig. 82.5).
Identifying an intact and stable posterior bony shelffrequentlythe orbital process of the palatine bone-during
fracture exposure is imperative for proper and anatomical
implant positioning. Dissection distances of 40 mm from
the infraorl>ital or medial orbital rim to identify this shelf
are often necessary in severe fractures. Dissection to the
stable shelf can be accomplished safely with meticulous
technique. Still, surgical dissection to this shelf brings the
swgeon within millimeters of the optic nerve. especially
when dissecting along the medial orbital wall. Medial wall
landmarks sudt as the ethmoid arteries must be utilized to
prevent injwy to the optic nerve.
New technologies including intraoperative cr scanning,
stereotacticguidance. and three-dimensional modelinghave
bolstered facial trauma swgeons' armamentarium for the
treatment of orl>ital fractures. Confirming anatomic reduction or repair with instant cr images is likely to improve
outcomes and can potenti.ally prevent or decrease costly
returns to the operating room for revision procedures. The
ability to preoperatively and intraoperatively mirror normal conttalateral skeletal structure with stereotactic guidance makes restoring normal anatomy a more attainable
goal in the most difficult cases where normal landmarks
have been obliterated. The production of a three-dimensional model from preoperative cr scans for reconstructive
planning can be useful in these circumstances as well. Use

of new imaging technologies will increase in coming }IleUS

as their availability expands and swgeons accumulate more
experience with these valuable tools.

Orbital Floor
Transcutaneous approaches to the orbital floor were the
mainstay for treatment of blow-out fractures for many
YQJS and continue to be in widespread use. Converse
originally described the subciliary approadt to the omit in
1944 (31). He and others have also advocated a subtarsal
variation of this approach. Both provide access to most of
the orbital ftoor. The orbital rim incision is an alternative
that the authors do not use or recommend because of the
potential for visible scarring.
For the subdliary and subtarsal approaches, local anesthetic with epinephrine is infiltrated subcutaneously in the
lower eyelid and along the inferior orl>ital rim. A lateral
temporary tarsonhaphy is performed on the operative
~ for protection and retraction. The subdliary cutaneous incision is made 2 mm below and parallel to the
lash line using a no. 15 blade (Fig. 82.11). The incision
should be carried no further medially than the lower lid
punctum. Laterally, the incision can be ex:tended up to
15 mm beyond the lateral canthus. If this lateral extension is performed, it should be directed horizontally and
not inferiorly to promote an aesthetically acceptable scar.
A subcutaneous dissection superficial to the orl>icularis
oculi is followed inferiorly using either sharp dissection
or the Colorado dissector until just inferior to the tarsal
plate where the orl>icularis is divided parallel to its :fibers.
It is crucial to presenre this rim of orbicularis over the tarsal
plate to maintain lower lid structure and support. A preseptal plane is then followed down to the orbital rim. The

-subciliary Approach
Subtarsal Approach

Figu,. 82.11 Paths traversed by the subciliary and sulmlrsal

approaches through Ute lower eyelid are shown. It is important to
step the incisions as shown to preserve lid integrity and avoid scar
inversion. (From Humphrey C, Kriet JD. Surgical approaches to the
orbit. Operat Tech Otofaryngol Head Neck Surg 2008;19:132-139,
with permi,ion).

Chapter 82: Orbital Fractures

periosteum is incised on the anterior aspect of the inferior
o:rbital rim, and elevation proceeds posteriorly onto the
o:rbital floor using a periosteal elevator. For the subtarsal
variation of this approach. the skin incision is made in
the subtanal fold or 5 to 7 mm below the lash line when
the fold is obscured by edema (Fig. 82.11). The orbicularis
oculi is divided a few millimeters below the level of the
skin incision to discourage scar inversion. Carefullayued
closure is the rule, taking care to restore o:rbicularis oculi
continuity. A Frost suture is sometimes used to suppon the
lid in the early postoperative period.
Over the past two decades, the transconjWlctival approach
has supplanted transrutaneous approaches in many surgeons' hands to decrease risks of postoperative lower lid
malposition. Bowquett :6m descn'bed the inferior fornix conjWlctival or ttansconjWlctival approach for blepharoplasty
in 1924 (32). Tenzel and Miller (33) later employed this
approach for repair of o!bital floor defects in the 1970s.
Exposure of most of the orbital floor can be achieved
through the transconjWlctival approach.
To prepare for the ttansconjWlctival approach, local
anesthetic with epinephrine is infilttated at the lateral canthus, just under the conjunctiva of the lower lid, and transrutaneously down to the orbital rim. Lateral canthotomy
and inferior cantholysis is optional and can be pe:rfonned
using auved iris scissors and is optional to increase surgical
exposure and minimize retraction of the lower eydid. Ifthe
canthal release is not pe:rfonned, great care must be taken
to avoid excessive retraction that may lead to a higher incidence of lower eyelid malposition. With a Jaeger lid plate
protecting the globe, the lower eyelid is everted and an incision is made with a Colorado dissector through the conjunctiva at least 2 mm inferior to the tarsal plate. The incision is
continued through the lower lid retractors. Blunt dissection
between the orbicularis oculi and o:rbital septum-a preseptal approach-proceeds using the malleable retractor and
cotton-tipped applicatoiJ. Alternatively, the orbital septum
can be incised to reveal a dissection plane between the
o:rbital septum and periorbital fat-a postseptal approach
(Fig. 82.12). A 5-0 silk mattress suture is placed through
posterior edge of the conjunctival incision and positioned
to passively retract the conjunctiva superiorly such that it
covers the globe. Blunt dissection with a malleable retractor
over the septum or o:rbital fat and a Ragnell retractor on the
lower lid and orbicularis oculi will reveal the periosteum of
the inferior o:rbital rim. The Colorado dissector is used to
incise the periosteum on the anterior surface of the rim. The
periosteum is elevated, and the malleable retractor can be
used to continually retract the o!bital contents and expose
the desired portion of the orbital floor. No closure of the
conjunctiva is needed so long as it is properly repositioned
at the conclusion of the procedure. If canthotomy and cantholysis are peJformed, the tarsal plate is resuspended to
the orbital periosteum near Whitnall tube:rcle using a single
5-0 polydio:z:anone suture. The canthus is reapproximated
using a single 6-0 fast absorbing gut suture placed through

1233

F'.gure 82.12 Patlu vaversed by the pre- and poNeptal variation!~

of the transc:onjunctival approach are shown. A hypothetical
ac:Mntage to the post:Septal approach is avoidance of undesirable
scar formation between the orbicularis oculi and orbital septum.
Such scar formation could contribute to postoperative lower lid
malposition. (From Humphrey C, Kriet JD. Surgical approache9
to the orbit. Operat Tech OtolffrY11gol Head Nedc. Surg 2008;19:
132-139, with pennission).
the grey line of the lateral upper and lower lids. Interrupted
sutures are used as needed to close any remaining canth.otomy defect laterally.
Advantages to the subciliary and subtarsal approaches
are that they are easy to learn and offer broad access to
the o:rbital floor. Disadvantages are higher rates of postoperative lower lid malposition and visible scarring when
compared with the transconjunctival approach (34,35).
Technique in a transcutaneous lower lid approach must be
flawless to minimize the risk of scleral show and ectropion.
Rohrich argues that the subtarsal variation of this approach
produces less risk of vertical lid shortening, scleral show;
and ectropion but slightly greater risk of visible scarring.
Innervation to the pretarsal and much of the preseptal
o:rbirularis is better prese:I'Ved through the subtarsal variant
which may help maintain the preoperative lower lid position (36). Advantages of the transconjunctival approach
include no visible scarring and decreased risk of ectropion
when compared with the subciliary and other transcutaneous approaches (34,35). While the continually protruding
periorbital fat can be an annoyance, a theoretial advantage
of the postseptal variant is decreased incidence of postoperative lower lid malposition since the plane between the
o:rbirularis oruli and o!bital septum is not violated.

1234

Section V: Trauma

A
Figure 82.13 A

1~

by 20-mm defect is 1hen created in the anterior wall of the maxillary sinus for
aCCIISS to Ute orbital floor. As shown, Ute medial buttnm,lateral lxmress, and inferior orbital rim remain intact (A). A Davida malleable neurosurgical retractor (Aexbar Machine Corporation, Islandia, NY} or similar is positioned to retract the ipsilateral cheek (B). {From Humphrey C, Krist JD. Surgical approaches to
the orbit. Openrt Tec:h Otolaryngol Head Ned Surg 2008;19:132-139, with permission).

A transantral endoscopic approach to the orbital floor

has been advocated by some swgeons (37). 1his approach

may be used as an isolated technique or combined with a
more traditional periorbital approach to assist in fracture
visualization and reduction. Endoscopic technique is not
indicated for and has lost favor for treatment of routine
orbital floor fractures (38).
The transanttal endoscopic approach begins with a
gingivolabial sulcus incision. The surgeon must presave a
4- to 5-mm ruff of mucosa on the gingival side for closure.

Maxillary periosteum is then incised. The lip is retmcted,

and a periosteal elevator is used to expose the anterior
wall of the maxillaJ:Y sinus up to the level of the inflaorbital nerve An osteotome and Kerrison rongeur are used
to make a 10 by 20 mm defect in the anterior wall of the
sinus (Fig. 82.13). Zero- and thirty-degree 4-mm telescopes

are then inserted through the antrostomy to visualize the

oibital floor (Fig. 82.14). The ftoor defect is usually obvious and mucosa can be elevated adjacent to the defect
for visualization and reduction of the OJbital contents.

B
Figure 82.14 A right orbital blow-out fracture as identified with CT (A) and as visualized
enc:lo!ICDpically via a transantral endosa:Jpic: ~ with herniation of bone fragments, periorbita, and
orbital fat into the maxillary sinus (B). (From Humphrey C, Krist JD. Surgical approaches to the orbit.
Operat Tec:h Oto/aryngo/ Head Neck Surg 2008;19:132-139, with permission).

Chapter 82: Orbital Fractures

1235

Semilunar fold

Figure 82.15 Orbital blow-out fracture shown In Figure 82.14

following reduction of herniated orbital fat and placement of a
Medpor linear high-density polyethylcme Implant (Porex Surgical
Inc, Newnan, GA) supported by the anterior and posterior shelves
of the ftoor defect. (From Humphrey C, Krlet JO. Surgical approaches to the orbit:. Operllt Tech Otolaryngol Head Neck. Surg
2008;19:132-139, with permission).
nap door or greenstick type fractures can occasionally be
reduced using this approach alone without need for fixation
if the bony floor "'ocka" into place. An implant can also be
inserted ifnecess;u:y by placing it :fu:st onto the posterior shelf
and then sliding it up onto the anterior shelf (Fig. 82.15).
Closure proceeds by reapproximating the gingivolabial sulcus mucosa using intmupted 3-0 polyglactin suture.
Reported advantages to the transantral approach
include improved visibility of the posterior orbit and especially the posterior shelf of a floor defect. Disadvantagl!s
include difficulty in reconstructing the o:rbital floor lateral
to the infrao:rbital nerve, the need to violate the anterior
maxillary face in an isolated orbital floor ftact.ure. and the
need for specialized endoscopic insttumentation. Though
perhaps a useful adjunct for complex cases, the transantral
endoscopic approach does not seem to decrease morbidity
or improve outcomes for most floor fractures (38).

Medial Orbit
Lynch :fu:st described his transcutaneous approach to the
medial o:rbit and frontal sinus for sinusitis in 1921. Though
refined somewhat, the approach is relatively Wlchanged
from this original description. Access to most of the medial
orbital wall is achievable through this approach (39).
Local anesthetic with epinephrine is injected over the
ipsilateral nasal bone and the medial orbital rim. An incision is made with a no. 15 blade over the superomedial
orbital rim from a point inferior to the medial brow to the
superior aspect of the nasofacial junction. This incision is
carried down through periosteum using the Colorado dissector. A periosteal elevator is used to expose the medial
orbital wall, staying superior to the medial canthal tendons
and lacrimal apparatus until posterior to these structures.

Figure 82.16 The 1ranscarunc:ular lndslon Is plaa~d either over

or just posterior to the caruncle In the sulcus between the carunde
and the semilunar fold. (From Shorr N, Baylis HI, Goldberg RA,
et al. Trancaruncular approach to the medial orbit and orbital apex.
Ophthalmology 2000;107:145~1463, with permission).
If exposing the superomedial orbit. care should be talren
to identify and cauterize or ligate the ethmoid arteries. The
anterior and posterior ethmoid arteries serve as a useful
depth gauge for the swgeon to estimate distance from the
optic canal.
An alternative to the Lynch incision is the transcaruncular approach as described by Shorr. It allows access to the
entire medial o:rbital wall posterior to the lacrimal fossa
via a conjunctival incision (40 ). A Colorado dissector is
used to make a 12 to 15 mm. incision either through or
just posterior to the caruncle and anterior to the semilWla!
fold (Fig. 82.16). The upper and lower lids are rettacted
with Desmarres retractors, and the globe is protected using
small malleable retractors. A plane posterior to Homer
muscle is developed with iris scissoiJ until the posterior
lacrimal crest is palpated. The Colorado dissector is then
used to incise the periosteum posterior to the lacrimal
crest. medial canthal attachments, and the lacrimal sac
(Fig. 82.17). The periosteum is elevated along the lamina
papyracea Wltil the desired exposure is obtained. The anterior and posterior ethmoid arteries are ligated as necess;u:y.
If exposure of both the medial wall and floor of the omit
is desired. the transcaruncular approach can be combined
with an inferior transconjunctival approach. In most cases,
an implant can be placed to reconstruct two-wall defects
while working around the inferior oblique muscle. If this
is not possible, the inferior oblique can be divided near
its insertion and reapproximated at the completion of the
case. 1he swgeon should realize that any manipulation of
the inferior oblique may have functional implications.
The transcaruncular approach is replacing Lynch's technique as the standard for access to the medial orbital wall
because it eliminates the potential for visible scarring and
webbing associated with the transcutaneous incision in this

1236

Section V: Trauma

Homtfsm.

Otbital septum

Ant. ettvnoid a.

Post. ethmOid a.

Figure 82.17 'Thcl1rlln5C8runcular approach follows a plane lmrntildlllt8ly postarior to Horner musdcl
down to the pc~riosteum of the medial orbital wall posterior to both the canthal attachments and
lacrimal apparatus (A). Periosteal elevation can then proceed without disturbing these structui'QS
(8). (From Shorr N, Baylis HI, Goldberg RA, et al. Trancaruncular approach to the medial orbit and
orbltalapc~x. Ophthalmology2000;107:1459-1463, with pc~rmlsslon).
area. One disadvantage to the uanscaruncular approach is
that it can be difficult to insert and manipulate an implant
through the relatively small incision. Care mwt be wed
to avoid injw:y to the lacrimal apparatus by following the
proper dissection plane to the posterior lacrimal crest
Similar to transantral approaches to the orbital floot;.
transnasal approaches to the medial orbit have been proposed. Rhee described wing a transnasal endoscopic
approach either to place stenting material between the
middle turbinate and a medial orbital defect or in conjunction with a transcaruncular or uansconjunctiwl approach
to facilitate precise placement of an implant for medial
orbital wall reconstruction (41 ).
Prior to inserting endoscopes, the nose is first decongested using ox:ymetazoline on Cottonoid pledgets.
A 4-mm 0 degree endoscope is then advanced into the nasal
c:avif. The middle turbinate is gently medialized with a
Frazier suction or blunt-tipped right angle probe to visualize the uncinate process. Local anesthetic with epinephrine
is injected along the uncinate process. A Kenison rongeur
is then wed to remove the uncinate,. leaving 3 to 4 mm
superiorly to prevent fonnation of nasofrontal recess synechiae. The ethmoid bulla and maxillary os are identified.
The majority of medial orbital injuries are associated with
nasal trauma, and there may be significant intranasal damage in addition to the prolapsing orbital contents. Care
must be taken to bluntly dissect the tissues and definitively
identify landmarks as one proceeds to avoid creating or
enlaJging an o:rbital or skull base defect The ethmoid bulla

is entered using a small Frazier suction, and the ethmoid

cells are opened back to the ground lamella. exposing the
lamina papyracea and medial orbital defect. Orbital contents can be carefully reduced using both the transorbital
and transna.sal approaches at this point When available, a
cr stereotactic guidance S)'8tem facilitates identification of
the orbital defect and skull base.
A combined approach to the medial wall may offer the
advantages of superior visualization and improved access
during implant manipulation. A disadvantage of the transnasal approach is the potential increased risk for skull base
injw:y and CSF leak. This approach also lacks utility as a
single approach because of both limited space for implant
introduction and the need to insert an implant blindly
toward the eye. No increased morbidity from sinus disease
postoperatively has been described (42).

Latwal Orbit and Orbital Roof

The lateral brow and upper blepharoplasty approaches are
useful for accessing the zygomaticofrontal and zygomaticosphenoid sutures, most often affected in ZMC fractures.
The lateral portion of the superior orbital rim and orbital
roof can be exposed as well. Incision placement for each of
these approaches is shown in Figure 82.3.
For the lateral brow approach, an incision is made just
inferior and parallel to the hair follicles of the lateral 2 to
3 em of the inferior brow. Some advocate making this incision within the bro~ but this may result in undesirable

Chapter 82: Orbital Fractures

1237

Zygomaticofrontal
Suture

.~

...........

--......... ...............

_../

,1'

FiguN 82..18 The brow incision is placed within or just below

Ute hair follicles of the lateral 2 to 3 em of the eyebrow. An upper
blepharoplasty incision is placad in the lateral one-Utird to one-half
of the supratarsal fold and can be extended as neawary, following
a horiz:ontal crease above Ute lateral canthus. (From Humphrey C,
Kriet JD. Surgical approaches to Ute orbit. Operat Tech Otolaryngol
Head Neck Surg 2008;19:132-139, with pennission).
alopecia The periosteum over the lateral orbital rim is
slwply incised and raised with an elevator to obtain the
desired exposure. Meticulous layered closure should reapproximate the periosteum. It is audal that meticulous
layered closure is performed to secure the periosteum aver
any plates and reestablish orl>icularis oculi continuity.
For the upper blepharoplasty approach, the supratarsal
fold is marked (tJpically 7 to 9 mm above the ciliary line).
The incision is extended within the fold and horizontally
beyond the lateral canthus in a rhytid or skin crease as
needed for exposure (Fig. 82.18). Local anesthetic with
epinephrine is injected subcutaneously and down to the
lateral orl>ital rim at the zygomaticofrontal suwre. The skin
is incised, and scissoiS or a Colorado dissector can then be
used to traverse the orbicularis oculi, dividing the muscle
parallel to the fibers. Dissection then proceeds to the lateral
orbital rim and zygomaticofrontal suture in a plane superficial to the orbital septum and laaimal gland. The periosteum is elevated aver the rim and zygomaticofrontal suture
as needed. If necessary, the supcriolateral orl>ital wall can
be dissected to assess zygomaticosphenoid suture alignment or gain access to the orbital roof (Fig. 82.19). Closure
is performed in layers, again meticulously reappraximating
the periosteum, orbicularis oculi muscle. and skin.
The primary advantage of the lateral brow approach
is the simplicitr of the technique. Disadvantages include
the possibility of visible scarring and brow alopecia. It
is because of this scarring that this approach has largely
been abandoned and replaced by the upper blepharoplasty

Zygomaticosphenoid
Suture

Figure 82.19 Zygomatfc:cfrontaland :eygcmatlcosphenold sutures

are exposed after subperiosteal elevation through an upper
blepharoplasty approach. (From Humphl'fOiy C, Krlcrt JD. Surgical
approaches to the orbit. Ope rat Tech Otolsryngol Head Nedc Surg
2008;19:132-139, wft:h permission).
approach. 1he advantages of the upper blepharoplasty
approach include ample access as well as a cosmetically
superior scar (43,44).
For more extensive aaniomaxillofadal reconstruction
requiring broader access to the supe:rolateral omit. the coronal
approach remains the workhorse. Additionally, it provides
access to the medial orbits and zygomatic arches. Access to
the lateral aspect of the infraorbital rims is possible by
extending the incision along the preauricular creases. 1he
coronal approach has been well described in the literature.
For further reading, Frodel provides an excellent discussion
of anatomical considerations and swgical technique for
this approach (45). 1he primcuy advantage of the coronal
flap is broad exposure and access to both orbits and the
nasal skeleton that is Wlparalleled by any other approach.
Disadvantages include incision length, extensive dissection, and potential morl>idity including alopecia, forehead
numbness. and potential for injury to the temporal branch
of the facial nerve.

POSTOPERATIVE CARE
Forted duction testing should be pelformed in the operating
room following any orbital approach with bony manipulation or implant placement There should be unrestricted
ocular mobility. Following swgery, the authoiS currently
observe most patients undetg<>ing orl>ital approaches in an
inpatient facility ove:migh.t. Observation in this setting expedites recognition and treatment of postoperative orbital
complications such as expanding hematoma. Vision checks
for light perception and acuity are performed every 4 hoUIS.

1238

Section V: Trauma

As previously disrussed, color discrimination is a very sensi-

tive indicator of optic nerve injury, and the ability to perceive

the color red is a useful bedside test Pain should also be
monitored closely. Corneal abrasion is the most common
cause of pain in the early postoperative period. However,
an expanding retrobulbar hematoma should be suspected
in the presence of progressive pain, visual changes, or
increasing proptosis. These findings should prompt physician evaluation. A determination can then be made whether
intervention or further observation is warranted.
Ice should be applied to the operative eye for 36 to
48 hours following surgery to decrease swelling and promote vasoconstriction. Tobramycin and dexamethasone
ointment is applied to the eye twice daily for 1 week to
maintain lubrication and decrease inflammation.

COMPLICATIONS
Diplopia
Diplopia may be the most common complication after
surgical treatment of orbital fractures. In many cases, it is
documented preoperatively and will persist temporarily
because of edema. Forced duction testing showing free ocular mobility at the conclusion of the procedure gives the
surgeon confidence that no persistent entrapment is present. Forced duction testing demonstrates dear improvement after release of entrapped rectus or periorbita in early
cases but can be much more ambiguous if a delayed repair
is performed (8). A postoperative cr scan can also be useful
for ruling out entrapped soft tissues. In cases of entrapped
rectus muscles that have been released, recovery of function
can take many months and may not be complete. If the diplopia is persistent and bothersome to the patient, referral to
ophthalmology is indicated for evaluation and treatment.

Vision Loss
VISion loss can occur with direct injury to the optic nerve
or its vascular supply. Intraoperative mydriasis is a sign
of pressure on the ciliary ganglion (located 1 em anterior
to the annulus of Zinn between the lateral rectus and
optic nerve). When mydriasis develops, it should serve
as a warning that excessive pressure is being applied
to the intraorbital contents; it is not necessarily a direct
indication that the optic nerve has been damaged (46).
Postoperative hemorrhage can result in blindness if not
treated immediately. If the patient develops visual changes
such as decreased color discrimination or loss of acuity
associated with increased intraocular pressure and proptosis, an expanding retrobulbar hematoma must be suspected. Canthotomy and cantholysis should be performed
immediately at the bedside to decrease intraocular pressure. Wound exploration, removal of the implant, and
hematoma evacuation in the operating room are also indicated. Immediate ophthalmology consultation should be

obtained in any case of decreasing visual acuity but should

not delay initial treatment.

Lid Malposition
Lower lid malposition in the form of retraction or ectropion is a complication that develops at least temporarily in
28% to 42% of transcutaneous approaches to the orbital
floor (34,35). In transconjunctival approaches, the combined incidence of ectropion, entropion, and scleral show
has been reported at less than 0.5% (47,48). Misplaced
conjunctival incisions or thermal cautery injury may damage the tarsal plate and increase the risk of entropion and
scleral show. There is also potential for symblepharon, or
scar formation between the tarsal and bulbar conjunctival
surfaces. A theoretical and controversial increased risk of
lower lid malposition exists using a preseptal rather than
a postseptal approach because of scar which may form
between the orbital septum and orbicularis oculi following a preseptal dissection. Some cases of postoperative
ectropion and entropion are transient and will resolve with
massage and observation over a few weeks. If persistent,.
surgical repair may be required for correction.

Orbital fractures requmng treatment commonly

occur secondary to blunt trauma incurred during
violent assaults, accidental injury (falls, sports
injuries, work-related), or motor vehicle accidents.
These patients must be initially evaluated according to current A1LS protocols. Once stabilized, the
facial trauma surgeon performs a focused orbital
evaluation.
Fine-cut cr scanning is the gold standard for
radiographic evaluation of orbital injuries. Axial
images are useful in evaluating medial wall fractures. Coronal images provide excellent views of the
orbital floor, medial wall, and roof. Sagittal images
are helpful in assessing the position of the stable
posterior shelf.
Clinical history should document mechanism of
injury, previous eye surgery, double vision. numbness, preinjury vision status, and comorbidities.
The physical examination should document visual
acuity, pupillary response. ocular trauma, globe
position, extraocular motility, diplopia, and cranial
nerve function.
Urgent treatment is indicated for dosed trap door
or "white-eyed blow-out fractures. These fractures
occur most commonly in the pediatric population
and may be associated with the OCR

Chapter 82: Orbital Fractures

Firm indications for repair of orbital blow-out

fractures include clinical enophthalmos or diplopia
associated with entrapment confirmed by forced
duction testing or radiographic imaging. The finding of inferior rectus rounding on cr scanning
may identify patients at risk for developing delayed
enophthalmos.
For orbital floor fractures, the transconjunctival
approach has largely replaced transcutaneous
approaches given a lower incidence of ectropion.
The transcaruncular approach is a versatile alternative to the Lynch approach for the treatment of
medial orbital wall fractures. The former avoids the
medial canthal scarring and webbing associated
with the Lynch approach.
The lateral orbital wall can be approached via an
upper blepharoplasty incision that avoids brow scarring. Exposure of the zygomaticofrontal and zygomaticosphenoid sutures is readily accomplished
with this approach.
Newer technologies include interoperative cr scanning and navigation, preoperative planning software. and rapid prototype modeling. Increasing
availability will assist surgeons in the successful
treatment of the most challenging cases.
While postoperative complications are rare, the clinical finding of progressive pain, increasing proptosis,
and visual changes should alert the physician to the
possibility of an expanding retrobulbar hematoma.
When suspected, emergent bedside canthotomy and
inferior cantholysis should be performed.

REFERENCES
1. Mellema PA, Dewan MA, Lee MS, et al. Incidence of ocular injury
in visually asymptomatic orbital fractures. Ophthal Plast Reconstr
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2. Ellis E, Zide MF. Surgical approache$ to 1M facial sk~leton, 2nd ed.
Baltimore MD: Lippincott Williams & Wilkins, 2006.
3. Larrabee WE Makielski KH. Surgical anatomy of the face. New
York Raven, 1993.
4. Zide BM. Surgical anatomy around th~ orbit. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.
5. Ellis E, Reddy L. Status of the internal orbit after reduction of
zygomatioomaxillary complex fractures. J Oral Maxl1lofac Surg
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6. Chi MJ, Ku M, Shin KH, et al. An analysis of 733 surgically treated
blowout fractures. Ophthalmologica 2010;224(3): 167-175.
7. Hwang K, You SH, Sohn IA. Analysis of orbital bone fractures:
a 12 year study of 391 patients. J Craniofac Surg 2009;20(4):
1218-1223.
8. Yano H, Nakano M. Anralru K, et al. A conse01tive case review of
orbital blowout fractures and reoommendations for romprehensive management F'fast Reconstr Surg 2009;124:602-611.
9. Carinci F. Zollino I, Brunelli G, et al. Orbital fractures: a new
classification and staging of 190 patients. J Craniofac Surg
2006; 17(6):1040-1044.
10. Zingg M. Laedrach. K, Chen J. et al. Classification and treatment
of zygomatic fractures: a review of 1025 cases. J Oral Maxillofac
Surg 1992;50:778-790.

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11. Haug RH, Van Sickcls JE.. Jenkins WS. Demographics and
treatment options for orbital roof fractures. Oral Surg Oral Mro
Oral Pathol Oral Radiol Endod 2002;93(3):238-246.
12. Deschamps-Braly JC, Sawan K, Iliff N, et al. Decision making
in isolated orbital roof fractures with a case report of the upper
eyelid approach to treatment Plast Reconstr Surg 2010;126(6):
30&-309e
13. I.e Fort R. Etude experimentale sur les fractures de la machoire
superieure Rev Chir d~ Paris 1901;23:208-479.
14. Waterhouse N, Lyne J. Urdang M, et al. An investigation into
the mechanism of orbital blowout fractures. Br J Plast Surg
1999;52:607-612.
15. Rhee JS, Kilde J. Yoganadan N, et al. Orbital blowout fracture:
experimental evidence for the hydraulic theory. An:h Facial F'fast
Surg 2002;4:98-101.
16. Greenwald MJ. Boston D, Pensler JM. et al. Orbital roof fractures
in childhood. Ophthalmology 1989;96(4):491-496; discussion
496-497.
17. Grant. MP. Prospective analysis of oOllar injuries with isolated
orbital floor fractures. Ophthal Plast Reconstr Surg. In Press.
18. Burnstine MA. Clinical reoommendations fur repair of orbital
facial fractures. Curr Opin Ophthalmol2003;14:236-240.
19. Holt JE, Holt R, Blodgett JM. Ocular injuries sustained during
blunt facial trauma. Ophthalmology 1983;90:14-18.
20. Jordan DR, Allen LH, White J, et al. Intervention within days for
some orbital floor fractures: the white-eyed blowout. Ophthal
Plast Reconstr Surg 1998;14(6):379-390.
21. Chen
Chen YR. Update on orbital reoonstruction. Curr Opin
Otoltn}'rlgol HMd Neck Surg 2010;18:311-316.
22. Malic DB, The R. Banerjee A, et al. Rounding of the inferior rectus
muscle as a predictor of enophthalmos in orbital floor fractures.
J Craniofac; Surg 2007;18(1):127-132.
23. Belli E, Mattcini C, Mazzone N. Evolution in diagnosis and
repairing of orbital medial wall fractures. J Craniofac Surg
2009;20(1):191-193.
24. Simon GH, Syed GJ, McCann JD. et al. Early versus late repair
of orbital blowout fractures. Ophthalmic Surg uum Imaging
2009;40:141-148.
25. Mohindra S, Mukherjee KK. Chhabra R. et al. Orbital roof growing fractures: a report of fuur cases and literature review. Br J
Neurosurg 2006;20(6):420-423.
26. Antonelli V. Cremonini AM, Campobassi A, et al. Traumatic
encephalocele related to orbital roof fractures: report of six cases
and literature review. Surg NNrol2002;57(2):117-125.
27. Kirby EJ, Thmer JB, Davenport DL, et al. Orbital floor fractures:
outromes of reconstruction. Ann F'fast Surg 2011;66:508-512.
28. Garibaldi DC, iliff NT, Grant MP. Use of porous polyethylene
with embedded titanium in orbital reconstruction: a review of
106 patients. Ophthal Plast Reconstr Surg 2007;23:439-444.
29. Ellis E, Thn Y. Assessment of internal orbital reconstruction fur
pure blowout fractures : cranial bone grafts versus titanium mesh.
J Oral Maxl11ofac Surg 2003;61:442-453.
30. Romano JJ, lliff Nr, Manson PN. Use of Medpor porous polyethylene implants in 140 patients with facial fractures. J Craniofac
Surg 1993;4:142-147.
31. Converse J, Two plastic operations for repair of orbit following severe trauma and extensive comminuted fracture. An:h
Ophthalmol1944;31:323.
32. 'Tessier P. The ronjunctival approach to the orbital floor and maxilla in rongenital malformation and trauma. J Maxillofac; Surg
1973;1:3-8.
33. 1enzel RR, Miller GR Orbital blow-out fracture repair, a conjunctival approach. Am J Ophthalmol1971;71 :1141-1142.
34. Appling WD, Patrinely JR. SalzerTA. Transoonjunctival approach
vs. subciliary skin-muscle flap approach fur orbital fracture
repair. Arc;h Otola1}"1gol H~d Neck Surg 1993;119:1000-1007.
35. Wray RC, Holtmann B, Ribaudo JM. et al. A romparison of conjunctival and subciliary incisions for orbital fracture. Br J Plast
Surg 1977;30:142-145.
36. Rohrich RJ, Janis JE, Adams WP. Subciliary versus subtarsal
approaches to orbitozygomatic fractures. Plast Reconstr Surg
2003;111:1708-1713.
37. Farwell DG, Strong EB. Endoscopic repair of orbital floor
fractures. Facial F'fast Surg Clin N Am 2006;14:11-16.

cr.

1240

Section V: Trauma

38. Farwell DG, Sires BS, Kriet JD. et al. Endoscopic repair of orbital
blowout fractures: use or misuse of a new approach? Arch Facial
Plast SUIX 2007;9(6):427 -433.
39. 4'nch RC. 1he technique of a radical frontal sinus operation
which has given me the best results. Laryngoscope 1921;31:1-5.
40. Shorr N, Baylis HL Goldberg RA. et al. Trancaruncular
approach to the medial orbit and orbital apex. Ophthalmology
2000;107:1459-1463.
41. Rhee JS, Chen cr. Endoscopic approach to medial orbital wall
fractures. Facial Plast Surg Clin N Am 2006;14:17-23.
42. Humphrey C, Kriet JD. Surgical approaches to the orbit. Oper
Thc:h Otolaryngol H~d Nec:k Surg 2008;19:132-139.
43. Kung OS, Kahan LB. Supratarsal fold incision for approach to the
superior lateral orbit. Oral SUIX Oral Med Oral Parhol Oral Radio!
Endod 1996;81:522-525.

AJ. Ziccardi VB, Granick M. Cosmetically favorable scars

using the upper blepharoplasty incision. Oral Su!X Oral Med Oral
Pathol Oral Radio! Endod 2004;98:627-628.
Frodcl JI. Marentette LJ, The coronal approach: anatomic and
technical considerations and morbidity. Arch Otolaryngol Head
Neck SUIX 1993;119:201-207.
Yeo MS, Al-Mousa R. Sundar G, et al. Mydriasis during orbital
floor fracture reconstruction: a novel diagnostic and treatment
algorithm. CraniomtuiUofac: Jtauma Rec;orutr 2010;3:209-21 G.
Westfall cr. Shore Jw. Nunery WR. et al. Operative complications
of the transconjunctival inferior fornix approach. Ophthalmology
1991;98: 1525-1528.
Mullins JB, Holds JB, Branham GB, et al. Complications of
the transconjunctival approach: a review of 400 cases. Arch
Otolaryngol Head Neck Su11 1997;123:385-388.

44. Rega

45.

46.

4 7.
48.

Grant S. Gillman

Carlos M. Rivera-Serrano

INTRODUCTION/PERSPECTIVE
The face is the most visibly apparent feature of the body,
and even a subtle alteration or asymmetry may be appreciable to the untrained eye. Due to the thin skin overlying the nasal dorsum, it has been said that a displacement
of even as little as a few millimeters may be perceptible
(1). Furthermore, beyond the aesthetics of the nose, it is
equally important to consider the functional impact that
trauma may bring to bear on the nasal airway.
Not swprisingly given the prominence of the nose as
a facial feature, the nasal bones are the most commonly
fractured of all facial bones and the third most common fracture of the adult human skeleton (2-14). It has
been estimated that there are approximately 50,000 nasal
fractures per year in the United States though the actual
number is likely higher due to underreporting, patients
not seeking medical attention, and fractures that are overlooked in the multitrauma setting (7,9). Nasal fractures
occur two to three times more frequently in males and
are most commonly seen between 14 and 50 years of age
(7) with a peak incidence between the second and third
decades of life (6).
Of all facial fiactures, about 40% involve the nose
(3,9,15). When one considers all patients with facial skeletal fractures, about 20% will have multiple facial bone injuries and so even in those cases where only an isolated nasal
fracture is suspected, it becomes critical to complete a thorough examination (16). Kim and Yoon (17) have reported
that 47% of all nasal bone fractures are associated with fractures of the nasal septum, and in a different study where
the septum was explored in all patients undergoing fracture
reduction, Rhee et al. ( 11) reported that septal fractures were
actually identified in over 90% of nasal fractures (8).
Individuals with a prior history of nasal fractures have a
15% to 20% chance of sustaining another nasal trauma in
the future, as the '"lifestyle" of some patients may increase

their predisposition to repeated nasal trauma (7). In those

who have had a prior rhinoplasty, the nasal bones may fracture more easily and the incidence of nasal bone fractures
may also be higher than in the general population (18).
There are multiple considerations, treatments, and differing opinions when it comes to the treatment of nasal
fractures but surgeons generally agree that an optimal outcome should address both cosmetic and functional issues.
Recommended treatments for nasal fractures range from
no intervention at all (if undisplaced and asymptomatic)
to extensive surgery using rhinoplasty techniques through
open approaches (19,20). One of the most challenging
aspects of managing nasal fractures remains the high incidence of a posttraumatic nasal deformity, either externally
or in terms of the nasal airway. At a minimum, the goal
of nasal fracture management should be to reestablish the
preexisting nasal airway and cosmesis. Beyond that. if there
was already preexisting pathology, one is very unli.keJy to
attain an optimal nasal airway and cosmetic result with
closed reduction techniques alone. The difficulty in the
management of nasal fractures is that even when they are
recognized, the mechanism of injury and pathophysiology
are often poorly understood leading to inappropriate treatment and suboptimal outcomes.

STRUCTURAL ANATOMY
The external nose is pyramidal in shape and mainly composed of the thin nasal bones, the thick frontal (ascending) process of the maxilla, the nasal process of the frontal
bone, and the upper and lower lateral cartilages. The paired
nasal bones articulate with each other at the midline, with
the frontal bone superiorly and ascending process of the
maxilla superiorly laterally (Fig. 83.1 ). The nasal bones
tend to be thinner and broader at their caudal end and
are therefore more vulnerable to fractures inferiorly than
superiorly (21) .

1241

1242

Section V: Trauma

The skin and soft tissue of the nose varies in thidmess,

being loose and thinner in the dorsum and upper third, and
thicker and more adherent at the tip (22). Sensory innervation of the nose is provided by branches of the ophthalmic
(V1) and maxillary (V2) divisions of the trigeminal nerve

PATHOPHYSIOLOGY-MECHANISM
OF INJURY

Anterior nasal spine

1, Asoending pi'OC9ss of maxilla; 6, Sphenoid Greater Win;
2, Fossa for lacrimal sac:
7, Body of maxilla:
3, Nasal bones;
8, Lacrimal bone;
4, Nasal septum;
9, Nasal process of frontal bone;
5, Sphenoid lesser wing;
10, Frontal bone (Glabella).

Figure 83.1 Structural anatomy of the nose.

The cartilages that contribute to nasal structure are the

upper lateral, lower lateral or alar, sesamoids, and the
quadrangular septal cartilage The niangular or trapezoidal-shaped upper lateral cartilages, by virtue of their attachments to the undersurface of the nasal bones superiorly
and the dorsal septum medially help provide significant
support to the midline location of the septum and the stability of the middle nasal vault (5,22). The lower third of
the nose is made up ofa complex architecture and relationships between the cartilages, nasal septum, and soft tissue.
'Ihe lower lateral cartilages are one of the major nasal tip
support mechanisms and the sttength, resiliency, and orientation of these structures will affect both tip projection.
tip symmetry/alignment. and stability of the lower third of
the nasal sidewall and the external nasal valve (23).
The nasal septum is made up of the quadrangular cartilage anteroinferlorly, the perpendicular plate of the ethmoid bone superiorly, and the vomer posteroinferiorly.
The quadrangular cartilage articulates along its dorsal
edge with the upper lateral cartilages and inferiorly along
the ftoor of the nose with the maxillary crest. The septal
cartilage acts as a central sttut or tent pole," supporting
the middle and lower thirds of the nasal donum (20,21).
The perpendicular plate of the ethmoid and the vomer
artirulate with the posterior end of the septal cartilage
caudally and the nasal bones anteriorly, but provide less
support to the upper third of the nasal dorsum than the
quadrangular cartilage does to the lower two-thirds of the
nose (20,21 ).
The nose has a very rich blood supply. The blood su~
ply of the aremal nose is provided through branches of
the internal and external carotid systems-the facial artery
anteriorly (which becomes the angular artery superomedially) and the infraOibital and ophthalmic arteries dorsally.
Internally, the blood supply to the lateral nasal wall comes
from the sphenopalatine artery posteroinferiorly, and the
anterior and posterior ethmoidal arteries superiorly (24).

Less force is required to fracture the nasal bones than any

other fracture of the facial skeleton (14,25,26). Blunt nasal
trauma is a more commonly seen mechanism of injury
than penetrating nasal trauma, and lateral forces occur
more frequently than frontal or inferior forces. Inherent
variations in anatomy as well as the amount and direction
of applied forces will influence the fracture pattern and
resulting deformity (14,25,26).
With respect to individual anatomic variation. comminuted fractures are more likely to occur in elderly patients
because their nasal bones tend to be thinner. In children.
dislocations are more common than fractures owing to the
fact that the nose has a higher proportion of cartilage to
bone in the pediatric population.
In general, the greater the force of impact the more
significant the expected nasal deformity. Furthermore,
because the caudal end of the nasal bones is thinnest. a
fracture of the thicker more cephalic aspect of the nasal
bones requires greater force and is therefore more likely to
be associated with other facial fractures.
While variability is inevitable with respect to both susceptibility to nasal fractures and nasal fracture patterns,
cadaveric studies have enabled some general observations
to be made (25,27,28). Although fmctures are more commonly caused by a lateral force, a blow from any vector can
fracture the nose A greater force is required to fracture the
nose from a frontal impact than lateral impact, because the
nasal bones are to some atent buttressed to a frontal blow
by the pe~pendirular plate of the ethmoid bone, the elasticity of the septal cartilage, the anterior nasal spine, and
the frontal process of the maxilla.
A less forceful lateral impact may result in undisplaced
sidewall fractures, without symptomatic nasal obsttuction
and should not require any manipulation or treatment.
With increasing lateral force an ipsilateral displaced nasal
bone infracture first occws, without affecting either the
septum or contralateral nasal bone (Fig. 83.2). This will
be apparent externally and can affect the nasal airway as
well and as such reduction is recommended. The ipsilateral depression may create the illusion of curvature to the
nose (F'tg. 83.3), but typically the contralateral bone is not
partirularly tender, thereby suggesting the diagnosis of a
unilateral fracture As force increases, a lateral impact will
break both nasal bones (often an ipsilateral infracture and
contralateral outfracture) (Fig. 83.4) as well as the bony
and/or cartilaginous septum secondarily with lateral displacement of the entire nasal pyramid and obsttuction of
the nasal airway (Fig. 83.5).

Chapter 83: Nasal Fractures

1243

FiguN 83.2 Mal CT scan showing unilateral depressed fracture

of left nasal bone.

Figure 83.4 Coronal CT scan showing bilateral displaced nasal

bone fractures with concomitant nasal septal fracture.

Figure 83.3 Unllmaral Impacted ICift nasal bone frac:tur. (arrow)

generating the Illusion of an apparent c:t~rvature of the nose to the
patient's right.

Similar to the situation with lateral forces, a lesser

amoWlt of frontal force may fracture the thinner distal end
of the rwal bones without visible displacement or atemal
deviation. If there is sufficient force for displacement of the
nasal bones, the upper lateral cartilages, which are attached
to the Wldeuurface of the nasal bones may get impacted
with the nasal bones or avulsed &om the nasal bones with
both an external deformity and a reduction in nasal airflow: As the force &om a frontal impact increases, the septum may buckle, dislocate, or fracture and the bony nasal
cap can be impacted (Fig. 83.6), comminuted, and splayed
with widening of the nasal bridge and lateral displacement
of the nasal bones. Fracture or dislocation of the septum
will inevitably lead to nasal airway obstruction.
A very forceful frontal or central impact to the osseous and cartilaginous nasal structures can be transmitted
posteriorly to the nasoorbitoethmoid (NOE) complex
leading to nasoethmoidal fracwres (8). A NOB fracture
is a complex fracture that can involve the nasal, ethmoid,
frontal, lacrimal, maxillary, and Oibital bones as well as
the cribriform plate. A complete review of NOE fractures
is beyond the scope of this chap~ but they should be
recognized as the treatment is far more complicated and
the sequelae, if Wltteated, much more disabling. These
patients will present with additional signs and symptoms
that can include marked periomital edema and ecchymosis, telecanthus, enophthalmos, epiphora, telescoping of the nasal dorsum with a flattened naso&ontal root
and midfacial retrusion, and possibly a cerebrospinal

1244

Section V: Trauma

Figure 83.5 Pa\ient with acute, bilateral displaced nasal bone

fractures.

fluid (CSF) leak. Further discussion and management is

reviewed elsewhere in this tat.
Injury to the nose from an inferior vector ia more likely
to traumatize the cartilaginous septum with or without a
fracture of the nasal bones themselves. Sufficient impact
from below can dislocate the caudal septum off of the

Figure 83.6 Axial CT scan showing Impacted fracture of bony

nasal cap.

anterior nasal spine or maxillary crest with displacement

to one side or the other. This can result in asymmetty of
the nostrils and nasal base, inferior septal spun, and even
twisting of the nasal tip because ofthe proximity ofthe caudal septum to the lower lateral cartilages. Fractures of the
septal cartilage can also occur with telescoping of segments
leading to columellar retraction and/or nasal obstruction.
The se'Vl!Iity of airway obstruction accompanying nasal
fractures depends on the location of the septal fracture and
the presence of septal displacement with the latter being
the most important variable in nasal obstruction (10). The
nasal septum functions somewhat as an enagy-abso:rbing
structure ( 8), with the ability to dissipate a certain amount
offon::e and rebound without significant deformity. Beyond
that point, the septum will either dislocate or fracture.
Dislocations, as opposed to fractures, are more commonly seen where the cartilage tends to be thicker and
stronger-namely right at the bony-cartilaginous interfaces (28), either posterosuperiorly at the pe~pendicular
plate of the ethmoid bone or inferiorly at the maxillary
crest On physical examination, this would cOlTf!Spond,
respec:tM!ly, to either angulation of the quadrangular cartilage at the junction with the perpendicular plate of the
ethmoid or the appearance of a long septal spur inferiorly.
Fractures of the septum on the other hand tend to occur
in the thinner central portion of the quadrangular cartilage
above the bony cartilaginous interface or through the bony
septum (ethmoid andforvomer) (28). In separate cadaveric studies, MUITaf et al. (25) and Harrison (28) noted
remarkably similar septal fracture patterns with application of sufficient impact force. The fracture line in the cartilaginous septum was typically several millimeters above
the maxillru:y crest. extending posteriorly into the bony
septum and auving upward through the vomer into the
vertical plate of the ethmoid to yield a Cshaped fracture
pattern (Fig. 83.7). Fracture fragments can then either
overlap, telescope, or pivot to obstruct the nasal airway.
Roluich and Adams (29) likewise noted that low-velocity
injuries tended to occur inferiorly as either dislocations or
fractures, while high-velocity injuries or frontal impacts
resulted in more extensive fractures in the thin central portion of the septal cartilage extending posteriorly into the
ethmoid or vomer.
Another observation ofMurray et al. (25) in their cadaveric study of fracture patterns was that if the nasal bones
were displaced by more than half the width of the nasal
bridge there was inevitably a concomitant Cshaped fracture of the bony and cartilaginous septum as described.
Under such circumstances, they concluded that open treatment of the septum with resection of the inrerlocked or
overlapped segments incorporating the fracture inferiorly
and posteriorly was required in order to achieve optimal
alignment of nasal injuries of this se'Vl!Iity. The implication of septal fractures as they relate to success or failure
in the management of nasal fractures is discussed at greater
length later in this chapter.

Chapter 83: Nasal Fractures

Figure 83.7 Typical nasal se~ptal fracture pattn sMn In cadav

r-1 = vome~r, PPE = pe~rpe~ndlcular plate of ethmoid

bone, QC =quadrangular cartilage~)

e~ric studle~s.

DIAGNOSTIC ASSESSMENT
The diagnosis of a nasal fracture is generally made based
on the history and clinical exam. Patients who present with
nasal trauma may well have additional injuries and should
be routinely examined in a comprehensive and orderly
fashion as with any other trauma patient to minimize the
likelihood of overlooking concomitant injuries.

History
A thorough. history is the cornerstone of the diagnosis and
will frequently guide the management of nual fractures
as wdl. It is helpful to lmow when the incident oCCUlTed,
the mechanism of the trauma, the direction of the force,
patient symptomatology (in particulcu;. whether or not
there has been any alteration in alignment or change in
the nasal airway), whether or not there is a prior history of
nasal trauma or nasal swgery, the patient's medical history
and como:rbidities, age. and patient apectatiom. Epistaxis
is comidered to be a sine qua non for nasal fractures (30)
and suggests a disruption of or tear in the nasal mucosa.
Understanding the mechanism of injury is helpful for
the workup and management of the patient with nual
trauma. but is not as aitical as the physical exam for planning the reduction or swgical technique. As discussed
earliet the velocity and force of impact will influence the
pattern and alent of the underlying injury. In general, a
greater impact should heighten one's suspicion for additional injuries, for a more complex nasal fracture pattern,
and for an associated septal fracture or dislocation.
The timing of the injury is another important variable
to know in the scenario of a nasal fracture. Management
decisiom regarding nasal and septal fractures depend on
reliable visual and tactile information that the swgeon
inteiprets when :first examining and later manipulating or
reducing the nasal complex. Excessive soft tissue edema

1245

can mask minor or modest irregularities and preclude an

acanate understanding of the fracture pattern and degree
of displacement. The classical two windows of opporwnity
for nasal fracture management described in the literature
are therefore based on the rationale of manipulating the
nasal complex. in the absence of significant edema. Nasal
edema is generally limited within the first 2 to 3 hoUIS
after the trauma. and has settled to a certain degree
5 to 10 days after the injury. On the other hand, after 2 to
3 weeks of healing a :fibrous union is developing across the
fracture line making the reduction more challenging and
often mandating the use of osteotomies that might have
otherwise been unnecessru:y to enable repositioning of the
nasal framework
As with any swgical patient. the past medical history is
relevant. A prior history of nasal and septal trauma or nual
surgery is an important comideration, as it may influence
the surgical approach as well as what outcome is potentially achievable. One should also review como:rbidities
and medications that may contraindicate swgery or influence choice of anesthesia.
It is essential, as much as is possible, to determine the pretraumatic appearance of the nose with respect to alignment
and likewise to inquire whether any nasal aiJ:way obstruction existed previously. An arute nasal fracwre in the setting
of an old fracture with secondary deformity is a challenging predicament. as simple dosed reduction then becomes
unlikely to completely achieve a perfect cosmetic or functional outcome. Patients may not always accurately desaibe
and differentiate between newt:r and older deformities;
therefore, a review of photographs dating from before the
injw:y can be very helpful. On the other hand, most patients
are more reliable when it comes to telling the surgeon about
the presence or absence of some degree of premo:rbid nasal
airway obstruction. Ultimately, it is perceived changes in
alignment and the rwal airway that are the two most important indications for which surgical inteivention is wammted.
Questions about rhinorrhea. and new snoring or sleep
apnea are also relevant. PeiSistent dear rhinorrhea after
nasal trauma should raise the suspicion of a skull base
or frontal sinus fracture and a CSF leak. In these cases, a
beta-2 transferrin test is helpful in assisting in diagnosis
and more detailed imaging (computed tomography (Cf]
scan) is warranted. New snoring or apnea may be comistent with new-onset nasal airway obstruction and elevated
airflow resistance.
Patient expectations are also very relevant to management
decisions. Expectations may vary by age, gmdet personality;
religion, profession, and education among other variables.
In general, there are three types of patients with displaced
nasal fradures that are encountered in clinical practice. There
are those that are not concerned about minimal or modest
change in their nasal appearance or nasal function, those
that ju.st want their pretraumatic appearance and/or function restored, and those that see the situation u an opportunity to improve their pretraumatic cosmetic appearance

1246

Section V: Trauma

andfor nasal function. Not uncommonly, older individuals

and males tend to be less concerned about changes in nasal
appearance or minimal degrees of nasal obstruction.
Those not interested in a reduction when indicated
should be advised of the potential for persistent deformity
or nasal obstruction. and the possibility of more involved
swgery if undertaken once all is healed. As regards cosmetic adjustments (over and above alignment) on the
other hand, caution should be exercised before agreeing
to undertake any effort to simultaneously implement aesthetic rltinoplasty as swelling and structural instability are
likely to thwart such efforts resulting in suboptimal outcomes or a higher risk of needing revision swgery. The fundamental objective of managing nasoseptal fracwres is that
at a minimum, the surgeon should strive to reduce the fractures to the pretraumatic baseline. In some cases, howeva;.
the surgeon may elect to improve the nasal airway at the
same time in the patient who had preexisting nasal airway
pathology even if not altered by the most recent trauma.
The patient's age is another important determinant in
the management of nasal and septal fractures. Nasal fractures in children are discussed later in the chaptei: Fractures
in elderly people are managed similarly to the rest of adult
population. Howevet owing to different expectations and
comorbidities, this patient population will often opt for a
less aggressive approach.

inspecting for a septal hematoma. absctSS, mucosal tears,

septal fractures, or dislocation off the maxillary crest
Mucosal tears have been found to be highly suggestive of
septal fractures ( 11). A3 noted earlier, dislocations or displaced and angulated fractures can be seen anywhere along
the septum but occur most commonly at or close to bonycartilaginous interfaces.
A septal hematoma is characterized by a reddish purple or bluish bulge or fullness along the nasal septum.
Septal hematomas can be unilateral or bilateral and typically involve the cartilaginous portions of the septum. If
suspected. on palpation of the suspicious swollen area
with an instrument or a cotton swab it will feel puffy and
compressible. Needle aspiration is &equendy diagnostic. If untreated, a septal hematoma can lead to infection,
abscess, and secondru:y septal cartilage necrosis with loss of
dorsal support and a supratip saddle deformity (Fig. 83.8).
In addition. fibrosis between the perichondrium and septal cartilage can also lead to septal deformities, a thickened
septum, and retraction of the columella (31 ). Small hematomas may be aspirated and observed, but larger hematomas may require incision and drainage, followed by nasal
packing to prevent reaccumulation. Systemic antibiotics
are recommended while packing is in place.

Physical Exam
1he goal of the physical examination should be to establish a diagnosis, determine whether or not associated injuries may exist,. and determine what if any intervention is
required. A complete external and endonasal evaluation
should be performed. VLSual inspection and palpation are
equally important.
Physical findings consistent with the diagnosis of a nasal
fracture include edema. infraorl>ital/paranasal ecchymosis,
tenderness to touch. bony crepitus, and possibly a palpable step-deformity if new. Any shift or displacement of
the nasal pyramid should be noted as well as depressions,
ridges, and whether the fracture is unilateral or bilateral.
Widening of the midface, tdecanthus, restricted extraocular movements, or dental malocclusion are not seen with
isolated nasal fractures and should alert one to investigate
for additional maxillofacial injuries.
Endonasal examination is performed with a nasal speculum and a headlight (anterior rhinoscopy) and, if available the use of a rigid nasal endoscope enables a more
complete evaluation. The endonasal exam is facilitated
by the use of a topical decongestant and local anesthetic.
Unfavorable functional and aesthetic outcomes are most
commonly related to unrecognized septal fractures with
significant displacement and accordingly an adequate and
complete exam of the nasal septum is critical ( 5,19,20,29).
Endonasal examination should include an assessment
of the septal position and nasal airway, in addition to

Figure 83.8 Supratlp saddle deformity, wtllch developed despite

drainage of a septal abSOiilss.

Chapter 83: Nasal Fractures

Imaging
Imaging is not routinely required for the diagnosis or clinical management of isolated nasal trauma (32,33). Both
false positives and false negatives are commonly seen with
plain radiographs and numerous reports have documented
their lack of utility in decision making as it pertains to the
management of nasal fractures (7,33,34). Old fracture
lines, vascular markings, suture lines, and overlapping
bone shadows can all be mistaken for fractures on plain
x-rays. Furthermore, as most nasal bone fractures heal by
a fibrous union, an older fracture line may remain visible
and therefore prior or preexisting fractures cannot be reliably distinguished from new ones with imaging. Facial
photographs are likely to be of greater benefit both clinically, and if necessary, medicolegally.
If, however, more extensive injury to the facial skeleton
is suspected, then a cr scan of the facial bones is warranted.
Not infrequently, patients will present to the surgeon with
a cr scan ordered for the workup of other injuries, and
while this might be helpful to classify or evaluate the characteristics of the fractures, the images are not ultimately
necessary for directing the management of isolated nasal
injuries.
There are some advocates of ultrasonography as an
emerging technology for the assessment and management
of nasal fractures. Different authors have suggested that
high-resolution ultrasound might be more accurate than
a cr scan (35) or plain x-ray (34), and that it may be useful in the evaluation of intraoperative repositioning of the
fractures (36). High-resolution ultrasonography has also
been reported to be helpful in establishing a diagnosis of
nasal fractures in children (3 7), but ultrasonography is
operator dependent and additional studies are required to
validate its efficacy.
Ultimately, whereas imaging may confirm a diagnosis or
facilitate classification. management decisions for isolated
nasal fractures are based primarily on a clinical evaluation.
The decision as to whether or not a nasal fracture requires
some kind of manipulation or surgical intervention should
be based on emergency findings (abscess, hematoma), an
alteration of form (alignment), or symptomatic nasal airway obstruction.

MANAGEMENT
Descriptions pertaining to the management of nasal fractures go back over 5,000 years. In the Surgical Papyrus,
Edwin Smith outlined treatment methods in ancient Egypt
whereby a linen wrap saturated with honey and grease was
introduced into each nasal cavity in order to then manipulate the nasal bones for fracture reduction ( 3 8). In the fifth
century BC, Hippocrates advocated early intervention to
reposition the nasal bones, but even at that time, he noted
that he was not able to realign the nasal bones appropriately if the septum was deviated (39). Twenty-five hundred

1247

years later, debate still exists over the optimal management

of the fractured nose and what operation to apply in which
circumstances.
Ideally, nasal fractures should be addressed within
the first 5 to 10 days of the injury. Beyond about 14 days,
the fracture may be less easily mobilized and reduced,
and the need for completion osteotomies becomes more
likely. Associated lacerations or soft tissue injuries should
be repaired within the first 24 hours and routine wound
care recommended. Application of ice packs or cold compresses over the first several days is helpful to reduce soft
tissue edema and facilitate better evaluation and intraoperative judgment.
If intervention is required, decisions then focus on location (emergency room [ER] vs. office setting vs. operating
room [OR]) and anesthesia (local vs. intravenous sedation vs. general anesthetic). Consider that maximal patient
comfort will enable the surgeon to apply as much force as
is necessary to disimpact and reduce fractures as well as to
provide the unhindered ability to progress to more complex intervention (septoplasty, osteotomies etc.) if needed.
Treatment in the OR provides the most favorable conditions (patient comfort, instrumentation, lighting, anesthesia options) and as such affords some advantage to the
surgeon and possibly therefore patient outcomes as well
Nasal fracture reduction may be performed under
local anesthesia (infiltrative and/or topical), intravenous
sedation, or general anesthesia. Both patient factors and
intrinsic nasal fracture factors will influence the choice of
anesthesia. Patient factors include the age, expectations,
tolerance, and comorbidities of the individual. Intrinsic
nasal fracture factors include the type and characteristics of
the nasal fracture and the status of the septum. Proponents
of local anesthesia for dosed reduction of nasal fractures,
particularly from the United Kingdom and Europe (20,4048), report that it is faster, uses less hospital resources, is
safer in elderly patients, produces minimal discomfort,
and has no effect on the result of the reduction ( 40-49).
The evidence suggests, however, that the debate between
local versus intravenous sedation versus general anesthesia
is somewhat aimless. It is not that one anesthesia technique
is better than the other. In the hands of an experienced
surgeon, both techniques are effective if the patient is
appropriately selected. In other words, a simple unilateral
fracture may be a reasonable candidate for reduction under
local anesthesia, whereas a comminuted bilateral displaced
fracture with associated displaced septal fractures is likely
better managed under general anesthesia. Ultimately, the
choice of anesthesia is a matter of surgeon preference but
undeniably a general anesthetic (this author's preference)
offers safety, a controlled and protected airway, maximum
patient comfort, and the uncompromised ability to examine, manipulate, and extend treatment if necessary.
The goal of treating nasal fractures has always been the
same-optimize cosmetic and functional outcomes, and
minimize revision rates. The traditional technique for

1248

Section V: Trauma

managing acute nasal fractures has been a closed reduction of the fractured nasal bones, and it remains the most
widely used today. As far as outcomes are concerned,
however, Staffel (50) reviewed 13 reported series of nasal
fractures treated with closed reduction alone and found
that while patient satisfaction rates in those publications
ranged anywhere from 62% to 91%, surgeon satisfaction
ranged from only 21% to 65%.
Accordingly. surgeons have sought to improve upon
outcomes. Treatment methods have expanded to now
include closed reduction, closed reduction with concomitant septoplasty; open reduction, open reduction with
concomitant septoplasty; and even early. primary functional septorhinoplasty in select cases. "Closed reduction
implies manipulation of the nasal pyramid with the use
ofbroad instruments and blunt (nonincisional) endonasal
techniques. "Open" reduction on the other hand generally
implies maneuvers requiring added access through intranasal incisions such as completion osteotomies or bone
rasping, for example, but is generally less involved than a
formal septorhinoplasty.
If the surgical procedure is well matched to the individual fracture. there is reason to believe that all approaches
can have equally good outcomes (19). The challenge then
becomes identifying which nasal fractures are well managed with a dosed reduction and which would merit a
more extensive procedure so as to maximize success rates.
Clearly. not all patients will do well with a closed reduction alone. and conversely not all patients need an open
reduction or primary septoplasty either.
The advantage of a closed reduction lies in the presumed
simplicity; shorter operative times, and limited morbidity
of the procedure, while the disadvantage may be a suboptimal outcome in more complicated fractures for which an
open procedure or septoplasty might have been warranted.
On the other hand, an open procedure-surely of outcome
benefit to some-involves longer operative times, a greater
burden of healing, and arguably the potential for surgical
cartilage depletion could make for more challenging revision procedures should they be necessary.
Interpreting published reports within the literature can
be difficult There are many variations from one study
to the next in terms of timing of treatment,. location of
treatment (ER vs. office setting vs. OR), type of anesthetic
administered (local vs. sedation vs. general anesthesia),
detailed description of technique or lack thereof, inconsistent reporting of assorted variables, unreliable patient
follow-up, ill-defined ..revisions" (airway vs. alignment vs.
bothi minorvs. major), and lack of dear fracture classification or treatment stratification among other things.
What has become apparent through various cadaveric
and clinical studies is that the greater the force or impact.
the greater the disruption and displacement of the nasal
bones and that in tum increases the likelihood of associated septal fractures and dislocations. As noted earlier,
both Murray et al. (25) and Harrison (28) demonstrated

somewhat predictable septal fracture patterns in cadaveric

models with application of increasing impact Murray et
al. also noted that if the fractured nasal bones were displaced by more than half the width of the nasal bridge
then a fracture of the septum was inevitable and in fact
many surgeons have used this as an indication for primary
concomitant septal surgery.
Rhee et al. (11), in a prospective study. actually explored
the septum through a hemitransfixion incision in all
52 patients with isolated nasal fractures undergoing a
dosed reduction in their study. They found that only two
patients had no septal fracture whatsoever, almost 80%
had an identifiable septal fracture with at least mild displacement or more. and 60% were classified as severely
displaced or worse (multiple fractures, crushed, comminuted). The presence of a mucosal tear was found to be
a statistically significant sign on physical examination
for septal fracture. They also found that while a cr scan
proved to be helpful in diagnosing septal fractures, it correlated poorly with the severity of the fracture. Their findings would suggest that even with relatively unremarkable
nasal fractures, septal fractures are a frequent occurrence.
This does not imply that all septal fractures are irreducible
or that all fractures require a septoplasty; but rather that
the frequency of septal fractures may be underappreciated.
The general consensus within the literature is that unrecognized overlapped, telescoped, or interlocked septal fracture fragments will lead to higher rates of post reduction
nasal deformities if unaddressed or if treated with closed
reduction alone (9,14,19,29,50). It has been said that "the
dorsum follows the septum," meaning that the nasal bones
will tend to migrate and heal in the direction of the septal deviation and so if significant septal fractures are not
addressed, optimal alignment of the nasal bones is unlikely.
With respect to management decisions regarding nasal
fractures, it is felt therefore that the single most important
determinant would be an accurate evaluation of the septum.
Furthermore. a graduated approach beginning with closed
reduction and progressing to septoplasty/open reduction if
unsuccessful is a reasonable strategy if the patient doesn't
have clear indications for one approach or the other.
An "ideal fracture classification scheme would guide
appropriate treatment. A variety of classification systems
have been proposed in the literature-based on factors
such as impact direction, injury plane. or anatomy (i.e.,
simple vs. comminuted; dosed vs. compound), for example. Unfortunately. these tend to be of academic interest
but provide litde in the way of dear treatment guidance.
Rohrich and Adams (29) proposed a classification
scheme and management algorithm, which enabled them
to achieve a revision rate of only 9%. In the case of apparent
septal fractures, they recommend either reduction of septal
dislocations (using an Asch forceps or Boies elevator) or
if the former is unsuccessful, proceeding with acute septal
reconstruction for which they generally advocate a limited
inferior and posterior resection.

Chapter 83: Nasal Fractures

1249

Evaluation

ClassHicatlon of Nasal and Septal Fracturas

Type

Dncrlption

Characteristics

Simple straight

UnUateral or bUateral displaced

fracture without resulting midline
deviation.

II

Simple deviated

UnUateral or bUateral displaced

fracture with resulting midline
deviation.
Bilateral nasal bone comminution
and crooked septum with
preservation of midline septal
support; septum does not interfere
with bony reduction.

Ill

Comminution of nasal
bones

IV

SIMirely deviated nasal Unilateral or bilateral nasal fractures

with severe deviation or disruption
and septal fractures
of nasal midline, secondary to
either sewre septal fracture or
septal dislocation. May be
associated with comminution of
the nasal bones and septum,
which interfere with reduction of
fractures.

Complex nasal and

septal fractures

Mobile
fracture

Severe injuries including lacerations

and soft tissue trauma, acute
saddling of nose, open compound
injuries, and avulsion of tissue.

Impacted or
incomplete
fracture

open repair
with
osteotomies

Less
severe
septal
deviation

Failure
either/or
option

More
severe
septal
deviation

Residual
deformity
or septal
deviation

Figure 83.9 Nasal fracture dassificat:ion scheme (A) and treatment algorithm (B) based on the fracture dassification. Reprinted from Ondik. MP et al. The treatment of nasal fractures: a changing paradigm. Arch Facial P/ast Surg
2009;11(5):296--302, with permission. Copyright C 2009 American Medical Association.

Ondik et al. (19) used a modification of the classification system proposed by Rohrich and then developed a
treatment algorithm based on their fracture classification.
Their classification and algorithm are seen in Figure 83.9A
and B. In their publication, if the septum did not interfere
with the bony reduction, then a dosed reduction alone
was used. On the other hand, if the septum was sufficiently dislocated or fractured so as to compromise midline support with severe deviation or disruption of the
nasal midline, then an acute septal repair was performed
together with completion osteotomies (if indicated). By
classifying patients and stratifying treatment accordingly.
they reported an overall revision rate of 6% (2% for dosed
reduction patients and 9% for those requiring open treatment, which is indicative of a more substantial fracture).
They concluded that if the choice of procedure is based
upon the type of fracture, both dosed reduction and open
procedures can have high measures of success.
Staffel (50) also developed and proposed a graduated
protocol for the treatment of nasal fractures, which begins
with dosed reduction and progresses as needed to include
a septoplasty (for persistent drift and/or preoperative nasal
airway obstruction), completion osteotomies (for persistent drift or memory), release of the upper lateral cartilages

(if the nose was crooked before the fracture or remains so

despite completion osteotomies), fracturing of the perpendicular plate of the ethmoid bone and lastly, camouflaging onlay grafts for any residual defects. The challenge with
this approach might be making some of the finer decisions
regarding drift or residual defects when confronted with
post-traumatic and intraoperative edema.
Over an 8-year period, Defatta et al. (14) studied only
those patients undergoing dosed reduction for a nasal bone
fracture in whom there was a persistent significant (not
defined) septal deformity identified intraoperatively after
dosed reduction. Under such circumstances, those undergoing concomitant primary septoplasty had lower rates of
residual septal deformity at follow-up (12.5%) than those
who did not (60% residual deformity). The number of
patients over that same time period who underwent dosed
reduction alone, in whom there was not a persistent septal
deformity identified intraoperatively. and their success/failure rates with those patients was not mentioned however so a
broader sense of perspective (i.e., what percentage of patients
are likely to fall into their treatment group) is not possible.
The treatment dilemma or the difficulty of choosing
the correct operation for a given patient is well expressed
by Fernandes (15) who commented that ...although it is

1250

Section V: Trauma

possible to predict the closed reductiolll!l that will definitely

faiL I am unable to predict those closed reductiolll!l that
will definitely succeed despite the patient having a sttaight
nose on the operating table.
Reasonable general recommendations therefore begin
with a full evaluation of the injury with particular attention paid to the possibility of septal fractures warranting
open treatment. A septal injwy more likely to warrant primaxy repair should be suspected with overlying mucosal
tea11 on physical examination. a collapsed or budded septum (often associated with acute loss of donal heightFig. 83.10), severe septal angulation posteriorly or inferiorly with symptomatic new-onset nasal airway obstruction. displacement of the external nasal framework by an
amount greater than half the width of the nasal bridge,
and nasal bones that prove to be irreducible with closed
reduction or continue to drift. Primary septal repait when
indicated, should be as conservative as is possible, with
partia:ilar attention focused toward inferior displacement
over the maxillary crest and posterosuperior fracwres and
angulation or telescoping at the junction of the quadrangular cartilage with the perpendia:ilar plate of the ethmoid
bone. Completion osteotomies are indicated for nasal
bones, which are displaced and impacted, thereby limiting
closed reduction or in situations where early treatment has
been delayed (beyond about 2 weeks) and the nasal bones
are somewhat immobile.
To summarize. because the untreated post-traumatic
nasal deformity-the crooked nose-can be one of the most
diffia:ilt of all septominoplasty procedures, effort should
be directed towaJ:d minimizing the need for revision procedures when treating an acute, displaced nasal bone fracture
in need of reduction. There is a place for both closed and
open procedures and properly applied, both can be successful. A1 the very least. the treating physician should colll!lider
the need for mending treatment beyond a closed reduction
alone, obtain proper colll!lent to proceed as necessa:r.y. and

Figure 83.10 Acutely budded SQptal fracture leading to Hptal

collapse, nasal airway obstruction, and supratlp depression seen
before open reduction with acutQ septal repair.

apply a graduated approach as dictated by the cirOJmstances.

In all cases, patients should be made aware preoperatively of
the possible need for a secondary swgery in the future.

NASAL FRACTURES IN CHILDREN

1he facial bones are much less commonly fractured in children than in adults, with children accounting for only 5%
to 10% of all facial fractures (51-53). Falls, blunt trauma,
and sports-related injuries are among the more frequent
causes, and facial fractures are more common among older
teens. Nasal septal deviations and nasal deformities can
also be seen in newborns in 1.25% to 23% of cases in association with intrauterine trauma. forceps-assisted deliveries, and breech deliveries (54).
The low incidence of facial fractures in children is a byproduct of the elasticity of the bones, craniofacial disproportion. and underdevelopment of the facial skeleton in
preadolescent children (51,53,55). With respect to nasal
fractures in particula~;. the child's nose is more cartilaginous
than bony and thus more resilient than that of an adult
Fractures of the nasal bones are thus less common, while
the cartilage, rather than fracture is more likely to budde,
twist. or dislocate. In such cases, septal mucoperich.ondrium may separate from the underlying cartilage, even
in the absence of mucosal tears or nasal bone fractures.
This creates a potential space in which rupture of smaller
vessels supplying the mucoperichondrium may lead to a
septal hematoma. which is thus more commonly seen in
pediatric nasal trauma than in adults (56). Should a hematoma evolve into a septal abscess, the likelihood of septal
cartilage destruction and long-term sequelae increases dramatically (57). For that reason. any child with a history of
acute nasal trauma complaining of nasal obstruction must
be carefully examined with that in mind.
Nasal fractures in children are often overlooked or
untreated, leading to adult nasal pathology (7,58). The
septum serves as one of the growth centen of the face until
about 12 to 13 years of age and as a result. nasal trauma at
a younger age may significandy affect subsequent growth,
form, and function (5,59). This undencores the importance
of establishing a diagnosis and administering treatment
when warranted, despite the inherent challenges in both.
Physical fincli.ngs are often less striking, particularly in
the very young child, and radiographs are of even less value
than in an adult due to the primarily cartilaginous nature
of the nasal structures in children. Substantial septal and
mucosal trauma can occur even in the absence of grossly
apparent external nasal deformity (58).
In the setting of nasal trauma in children. a histoJ:y of
associated epistaxis, nasal obstruction. and/or subde physical findingB such as nasal do:rsal edema. dorsal tenderness,
perio:rbital ecchymosis, and bony crepitus should elevate
the examiner's index of suspicion as well the more obvious
finding of a visible me:mal deformity or grossly abnormal
radiographs. A suspicious or inconsistent history, associated

Chapter 83: Nasal Fractures

Wlaplained injuries, ora history ofrepeated trauma should

prompt consideration of possible child abuse. Given the
sequelae that can develop as a result of Wldiagnosed nasal
or septal &acturea/dislocations in children. a proper and
thorough intranasal examination is required for a complete
eya)uation and to rule out septal pathology. this can be
challenging in 1he noncompliant child, and in some cases a
general anesthetic may be necessary to do so.
Pediatric &actures begin to heal and Wlite mudt quicker
than those of adults so when intervention is necessazy. It
should be Wldertaken within the first week if at all possible. The general approadt to the surgical treatment of nasal
fractures in children is one that emphasizes conservatism.
A septal hematoma or abscess should be drained in
all cases. For &actures, a closed reduction is the preferred
approadt for all pediatric nasal &actures to decrease the
possibility of interference with the bone growth centersonly highly displaced &actures should Wldergo open
reduction andfor primacy septal surgecy {53). If closed
reduction is unsuccessful and open reduction is indicated,
1he objective at that point should be maximal tissue preservation while optimizing nasal airway function and external alignment Dissection and excision of tissue should be
minimized to whatever extent possible.

TECHNIQUE

Closed Reduction
As mentioned earlie:t closed reduction implies manipulation of the nasal pyramid with the use of broad instruments and blWlt (nonindsional) endonasal techniques.
Once the patient is anesthetized or the field is blocked,
1he nose is decongested with pledgets soaked with a topical vasoconstrictor (e.g., oxymetazoline) to open the nasal
airway, improve visualization, and decrease bleeding with
manipulation. Injection of lidocaine and epinephrine can
also be used if desired, but is not absolutely necessary.
The typical instrumentation needed for a basic closed
reduction is seen in Pigure83.11. Simple, unilateral depressed
nasal bone fractures can be easily reduced using a broad :Oat
elevator sudt as a Boies elevator. In such cases, measuring
the distance from the nostril rim to the medial canthus externally will give the swgeon a sense of how far into the nasal
cavity the elevator must be passed to rest beneath 1he nasal
bone in question. With the elevator thus positioned endonasally, the thumb (for a right nasal bone fracture) or the
index. and long fingers (for a left nasal bone fracture) of the
opposite hand is placed am- the ipsilateral nasal bone, in
order to maximize fine control and provide tactile feedback
to the surgeon as the nasal bone is repositioned (Pig. 83.12).
the nasal bone is then elevated along a vector opposite the direction of impact or bone displacement A palpable if not audible repositioning of the bone should be
evident Typically, unless severely comminuted, the edges
of fracture &agments will interdigitate sufficiently to hold
the reduced bone in position. The Boies elevator can also

1251

Figure 83.11 Typical inJtrumem:ation needed for a dosed reduction-{left to right)-Walsham foi'CIIIp, Boies elevator, Asch fore~~p,
nasal speculum, nasal suc1ion, bayonet forceps.

be used to reduce a septum, which is dislocated inferiorly

back onto the maxillary crest or into the vomerine groove
A Walsham forcep is another instrument that can be used
for unilateral nasal bone &acture reduction in lieu of the
Boies elevator-it too is designed for manipulation of the
nasal bone of one side. With the Walsham forcep, one
blade rests in 1he nasal cavity while the other rests externally on 1he skin overlying the nasal bone for complete
control of the nasal bone during reduction.
While 1he Boies elevator is well suited for reduction of a
simple unilateral nasal bone &acture, it is less well applied
to bilateral displaced nasal bone &actures. The Asdt forcep ofi'eu ideal control of the entire nasal pyramid, in contrast to the Boies elevator or Walsham forceps, whidt limit
1he manipulation to one side. the Asch forceps is inserted

Figure 83.12 Bimanual dosed reduction tQchnlque us!ng Boles

elevator to radue unilateral depressed nasal fracture.

1252

Section V: Trauma

Open Reduction
Open reduction involves the repositioning of the nasal
stiUCtllreS via clifferent mucosal and skin incisions, with
techniques fundamentally similar to the ones used in functional and cosmetic Ihinoplastytechniques. Open reduction
techniques, from septoplasty to osteotomies to functional
primaxy septorhinoplasty can be of such range that they
are beyond the pwview of this chapter but are referenced
in part or whole elsewhere in this text. It is worth, howevet
emphasizing once again the importance of septal reduction
to enable satisfacto:ry repositioning of the nasal bones-an
inadequate reduction of the nasal septum impedes appropriate repositioning of the exte:mal nasal framework.

COMPLICATIONS
Complications of nasal fracwres may present in an early or
a delayed fashion. A list of more commonly encountered
early and late complications is provided in Table 83.1.
Figure 83.13 The Asch foroaps Is positioned astride 1fle nasal
septum to enable dlslmpaction and manipulation of 1fle entire
nasal pyramid.

straddling the septum, with one blade in each nostril in

order to "hug the nasal sepwm (Fig. 83.13). thin pledgets can be left in place on each side, between the tine of
the reduction forcep and the septal mucosa to protect the
mucosa from further trauma during reduction.
the septum and the nasal pyramid are carefully disimpacted, elevated, and repositioned by manipulating the
forcep in the direction opposite that of the fracture impact.
1he .Asch forcep has the distinct advantage of giving the
swgeon control over both nasal bones simultaneously and
as a single unit. As an added advantage, the Asch forcep
serws as a septal reduction forcep as well and some septal
fractures may be reduced concurrent with the movement
of the nasal bones. In the case of bilateral nasal bone fractures, if the bone on the side opposite the direction of displacement has been noticeably impacted, once the entire
nasal framework is repositioned to the midline with the
Asch forcep, the impacted nasal bone can be gently elevated into position with the Boies elevator.
Both nasal bone and septal reposition maneuvers are
repeated as necessar:y to obtain the best results; howevet
excessive manipulation and trauma should be avoided.
Once properly positioned, a standard external nasal splint
can be applied. Packing the nose is not generally needed
although it may help to provide early intranasal support to
a badly comminuted or unstable fracwre. If a concomitant
septoplasty is performed, Doyle splints are used postoperatively to stabilize the septal alignment. External and any
internal splints are removed the week following swgecy.
Prophylactic antibiotics are used in cases where internal
splinting or packing is used.

Early
Edema and ecchymosis are typically seen early and are
more expected than indicative of a complication. Both
should resolve spontaneously within 1 to 2 'Wf!eb.
Epistaxis is not at all uncommon, and most cases will
resolve spontaneously. Less commonly, cauterization or/and
intmnasal packing may be required. and swgay (elf!drocautely or 'ftSSelligation) and/or embolization is reserved for
the very rare refracto:ry atSeS. When packing a nose in the setting of a nasal fracwre, care should be taken to not to overpack for fear of interfering with blood supply to the already
damaged septum. ln. the setting of suspected skull base fracwres, packing is relatively contraindicated and should be performed only under direct visualization and with total control
in order to avoid inadvertent intracranial complications.
Wound infections are uncommon, although they can
develop with contaminated nasal lacerations (compound
fractures). A higher incidence of wound infection can be
seen in smokers, diabetics, immunocompromised patients,
and those with autoimmune diseases and with poorer
nutritional status (60).

II

COMPLICAllONS
NASAL FRACIURES

Early

Epi=naxis
Wound infection
Septal hematoma
Septal abscess
CSFieak

Nual airway obsvuction

Synechiae
Septal perforation
Crooked nose/extemal def'onnity
Saddle def'onnity
CSFieak

Chapter 83: Nasal Fractures

As disrussed earlier, a septal hematoma should be

suspected with abnormal bluish-purplish compressible
swelling over the septum and complaints of nasal pain or
congestion that seem beyond the norm for a nasal fracture.
Clinical examination establishes the diagnosis, and treatment, whether by aspiration or formal drainage, is essential. Failure to recognize a septal hematoma can result in
progression to a septal abscess with secondary cartilage
necrosis and saddling of the nasal dorsum.
A CSF leak may be associated with fractures of the cribriform plate or posterior wall of the frontal sinus, and usually
present with dear fluid rhinorrhea. This may be evident early
but in some circumstances may not manifest for months or
even years after the initial traumatic event. As noted earlier,
if suspected a beta-2 transferrin test is helpful in assisting
in diagnosis, and more detailed imaging (Cf scan) is warranted. Smaller leaks often go undetected and may in fact
resolve spontaneously. Otherwise, management will depend
on etiology and may require neurosurgical consultation.

Late
Late complications are often preventable with proper
early evaluation, diagnosis, and appropriate management
Delayed complications may be either functional or cosmetic, and are generally secondary to anatomic displacement and deformity of nasal structures, or tissue loss.
Delayed presentation of a CSF leak is noted above.
Delayed complications can include external nasal deformities (a crooked nose or saddle deformity), or endonasal
deformities such as nasal airway obstruction (deviated septum, valve collapse), intranasal synechiae, and septal perforations. Disruption of facial growth centers in children
can also lead to delayed functional or cosmetic problems.
Treatment of delayed complications ranges from primary
septoplasty to functional and/or cosmetic rhinoplasty,
which are discussed elsewhere in this text.

The nasal bones are the most commonly fractured

facial bone and the third most commonly fractured
bone in the body
A complete evaluation should take into account the
possibility of other facial skeletal fractures
The greater the impact resulting in a nasal bone fracture the higher the likelihood of associated nasal
septal fractures
Closed reduction and open reduction are both reasonable treatment options-successful management is predicated upon carefully considering which
approach is necessary for a given patient's fracture
Physical findings may be more subtle in children
and the incidence of septal hematoma is higherboth of which mandate greatervigilance

1253

REFERENCES
1. McCollough EG. Rhinoplasty: a humbling experience. J Oral
Maxl1lofac Surg 1989;47:1132-1141.
2. Fanahi T, Steinberg B, Fernandes R, et al. Repair of nasal complex
fractures and the need for secondary septa-rhinoplasty. J Oral
Maxl1lofac Surg 2006;64:1785-1789.
3. Hung T, Chang W, Vlantis AC, et al. Patient satisfaction after
dosed reduction of nasal fractures. Arch Facial Plast Surg
2007;9:40-43.
4. Ochs M. Fractures of the upper facial and midfacial skeleton. In:
Myers EN, ed. Operative Otolaryngology-Head & Neck Surgery.
Philadelphia, PA: Saunders Elsevier, 2008:905-960.
5. Higuera S, Lee EL Cole P. et al. Nasal trauma and the deviated
nose. Plast Reconstr Surg 2007;120:64S-75S.
6. Atighechl S, Karimi G. Serial nasal bone reduction: a new
approach to the management of nasal bone fracture. J Craniofac
Surg 2009;20:49-52.
7. Perkins SW, Dayan SH. Management of nasal trauma. Aesthetic
Plast Stag 2002;26(Suppl 1) :S3.
8. Lee SJ, Liang K. Lee HP. Deformation of nasal septum during
nasal trauma. Laryngoscope 2010;120:1931-1939.
9. Reilly MJ. Davison SP. Open vs dosed approach to the nasal
pyramid for fracture reduction. Arch Facial Plast Surg 2007;9 :
82-86.
10. Chun Kw; HanSK. Kim SB, et al. Influence ofnasal bone fracture
and its reduction on the airway. Ann Plast Surg 2009;63:63-66.
11. Rhee SC, Kim YK. Cha JH, et al. Septal fracture in simple nasal
bone fracture. Plast Reconstr Surg 2004;113:45-52.
12. Hwang K. You SH, Kim SG, et al. Analyais of nasal bone fractures; a six-year study of 503 patients. J Craniofac Surg 2006; 17:
261-264.
13. Hwang K. Lee HS . Early reexploration after dosed reduction of
nasal bone fracture. J Craniofac Surg 2010;21:603-635.
14. DeFatta RJ, Ducic Y. Adelson Rr, et al. Comparison of dosed
reduction alone versus primary open repair of acute nasoseptal
fractures. J Otolaryngol Head Neck Surg 2008;37:502-526.
15. Fernandes SV. Nasal fractures: the taming of the shrewd.
LaryngoswpB 2004; 114:58 7-592.
16. Dingman RO CJ, The clinical management of facial injuries and
fractures of the facial bones. In: Converse J. ed. Reconstrw;tivB plastic surgery. Philadelphia. PA: W. B. Saunders, 1977:599-747.
17. Kim JE, Park PH, Yoon CH. Analysis of nasal septal fracture combined in nasal bone fracture using cr.J Korean Soc Plast Reconstr
Surg 1998;25:852.
18. Guyuron B, Zarandy S. Does rhinoplasty make the nose more
susceptible to fracture? Plast Reconstr Surg 1994;93:313-317.
19. Ondik MP. Upinski L Dezfoli S, et al. The treatment of nasal
fractures: a changing paradigm. Arch Facial Plast Surg 2009;11 :
296-302.
20. Mondin V. Rinaldo A. Ferlito A. Management of nasal bone fractures. Am J Otolaryngol2005;26:181-185.
21. Gray H. Anatomy of the human body. Philadelphia. PA: Lea &.
Febiger, 1918.
22. KOppe T, Giotakis EL Heppt W. Functional anatomy of the nose.
Facial Plast Stag 2011;27:135-145.
23. l.ai A. Cheney ML. External nasal anatomy and its application to
rhinoplasty. Aesthetic Plast Surg 2002;26(Suppl1):S9.
24. Toriumi DM, Mueller RA. Grosch T, et al. Vascular anatomy of
the nose and the external rhinoplasty approach. Arch Otolaryngol
Head Neck Stag 1996;122:24-34.
25. Murray JA. Maran AG, Mackenzie IJ. et al. Open vs. dosed reduction of the fractured nose. Arch Otolaryngol19 84; 110:79 7-802.
26. Hampson D. Facial injmy: a review ofbiomechanical studies and
test procedures for facial injury assessment J Biomeclt 1995;28: 1-7.
27. Murray JA. Maran AG, Busuttil A. et al. A pathological classification of nasal fractures. InjU1}' 1986;17:338-44.
28. Harrison DH. Nasal injuries: their pathogenesis and treatment.
Br J Plast Surg 1979;32:57-64.
29. Rohrich RI. Adams WP. Jr. Nasal fracture management minimizing secondary nasal deformities. Plast Rer:onstr Surg 2000;106:
266-273.
30. Wang 1D FG, Kern EB. Nasal fractures. In: Gates A. ed. Current
therapy in otolaryngology: head and neck surgery. Philadelphia. PA:
BC Decker, 1990:105-109.

1254

Section V: Trauma

31. Adamson JE, Horton CE, Crawford HH, et al. Aolte submucous
resection. Plast Reconst:r Surg 19 68;42: 152-154.
32. Logan M. O'Driscoll K. Masterson J. The utility of nasal bone
radiographs in nasal trauma. Clin Radiol1994;49:192-194.
33. Sharp JF. Denholm S. Routine X-rays in nasal trauma: the
influence of audit on clinical practice. J R Soc Med 1994;87:
153-154.
34. Gurkov R. Clevert D, Krause E. Sonography versus plain x rays in
diagnosis of nasal fractures. Am J Rhinol 2008;22 :613-616.
35. Lee MH, Cha JG, Hong HS, et al. Comparison of high-resolution
ultrasonography and computed tomography in the diagnosis of
nasal fractures. J l.ntrasound Med 2009;28:717-723.
36. Park CH. Joung HH, Lee JH, et al. Usefulness of ultrasonography in
the treatment ofnasal bone fractures. J '1tauma 2009;6 7:1323-1326.
37. Hong HS, Cha JG, Pail< SH, et al. High-resolution sonography
for nasal fracture in children. AJR Am J Roentgmol 2007;188:
W86-W92.
38. Breasted J, Th~ Edwin Smith surgical f1a11YT'W. Chicago, IL:
University of Chicago Press, 1930.
39. Pumaropoulos G, Emmanuel C. Hippocrates, all his worils. Athens:
Naninos, 1971.
40. Khwaja S, Pahade AV. LuffD, et al. Nasal fracture reduction: local
versus general anaesthesia. Rhinology 2007;45:83-88.
41. Spielmann PM. Nasal fracture manipulation under local anaesthetic without injections. Clin Otolaryngvl 2007;32:503.
42. Houghton OJ, Hanafi Z, Papakostas K. et al. Efficacy of external
fixation following nasal manipulation under local anaesthesia.
Oin Owlaryngvl Allied Sci 1998;23:169-171.
43. Newton CR. White PS. Nasal manipulation with intravenous
sedation. Is it an acceptable and effective treatment? Rhinology
1998;36:114-116.
44. Green KM. Reduction of nasal fractures under local anaesthetic.
Rhinology 2001;39:43-46.
45. Rajapakse Y, Courtney M, Bialostocki A. et al. Nasal fractures: a
study comparing local and general anaesthesia techniques. ANZ
J Surg 2003;73:396-399.
46. Wild DC, El Alami MA. Conboy PJ. Reduction of nasal fractures under local anaesthesia: an acceptable practice? Surgeon
2003;1:45-47.

47. Chadha NK, Repanos C, Carswell AJ. Local anaesthesia for

manipulation of nasal fractures: systematic review. J Laryngol Owl
2009;123:830-836.
48. Repanos C, Anderson D, Earnshaw J, et al. Manipulation ofnasal
fractures with local anaesthetic: a how to do it" with online
video tutorial. Emerg Med Awtralas 2010;22:236-239.
49. Atighechi S, Baradaranfar MH, Akbari SA. Reduction of nasal
bone fractures: a comparative study of general, local, and topical
anesthesia techniques. J Craniofac Surg 2009;20:382-384.
50. Staffel JG. Optimizing treatment of nasal fractures. Laryngoscope
2002;112:1709-1719.
51. Imahara SD, Hopper RA, Wang J. et al. Patterns and outcomes
of pediatric facial fractures in the United States: a survey of
the National Trauma Data Bank. J Am Coli Surg 2008;207:
710-716.
52. Anderson PJ. Fractures of the facial skeleton in children. Injury
1995;26:47-50.
53. Ferreira P, Marques M. Pinho C, et al. Midfacial fractures in children and adolescents: a review of 492 cases. Br J Oral Maxillofac
Surg 2004;42:501-505.
54. Podoshin L, Gertner R. Fradis M, et al. Incidence and treatment of deviation of nasal septum in newborns. Ear Nose Throat
J 1991;70:485-487.
55. Zerfowski M, Bremerich A Facial trauma in children and adolescents. Oin Oral Investig 1998;2:120-124.
56. Stucker FJ J~; Bryarly RC, Shockley WW. Management of nasal
trauma in children. Arch Otolaryngvl1984;110:190-192.
57. Alvarez H, Osorio J, De Diego JI, et al. Sequelae after nasal septum injuries in children. Auri.s Nasus Larynx 2000;27:339-342.
58. Olsen KD, Carpenter RJ Ill, Kern EB. Nasal septal injury in children. Diagnosis and management Arch Otolaryngvl 1980;106:
317-320.
59. Grymer LF. Gutierrez C, Stok5ted P. Nasal fractures in children: influence on the development of the nose. J I.aryngvl Owl
1985;99:735-739.
60. Immerman S, Constantinides M, Pribitkin EA. et al. Nasal
soft tissue trauma and management. Facial Plast Surg 2010;26:
522-531.

E. Bradley Strong

BACKGROUND
While frontal sinus injuries are relatively uncommon, the
potential for long-term sequelae is significant. It is therefore critical to have a comprehensive treatment strategy.
Unfortunately, optimal management of frontal sinus fractures remains controversial (1-8). Most authors would
agree that a hierarchical treatment strategy would include:
treatment of any intracranial injury. avoidance of shortand long-term complications such as mucoceles, reestablishment of an aesthetic facial contour, and return of
normal sinus function if possible. This chapter provides an
anatomically based treatment algorithm for the management of frontal sinus fractures, highlighting the key steps
to surgical repair.

ANATOMY
The frontal sinus is not present at birth. The anterior
ethmoid air cells invade the frontal bone at age 2; developing into a full size frontal sinus by age 15 (Fig. 84.1).
The floor of the sinus forms the medial portion of the
orbital roof. The posterior table forms a portion of the
anterior cranial fossa. The anterior table forms part of
the forehead, brow, and glabella (Fig. 84.2). The size
and shape of the adult frontal sinus is highly variable. It
is commonly asymmetric and may be divided by one
or more septations. Less frequently, patients will have
a unilateral (10%), rudimentary (5%), or no frontal
sinus (4%). Average frontal sinus dimensions are: height
30 mm, width 25 mm, depth 19 mm, and volume 10 mL.
The anterior table is much thicker (average 4 mm, but up
to 12 mm) than the posterior table (0.1 to 5 mm) (9,10).
The nasofrontal recess is the sole outflow tract for the frontal sinus. The ostia are approximately 1 to 3 mm in diameter and located posteriorly, inferiorly, and medially on the
floor of the sinus (9, 10). They are the narrowest point of an

hourglass configuration, with the frontal sinus infundibulum above, and the nasofrontal recess below (Fig. 84.3).

PATHOPHYSIOLOGY
The frontal sinus is protected by thick cortical bone and is
more resistant to fracture than any other facial bone ( 11)
(Fig. 84.4). Consequently, frontal sinus fractures account
for only 5% to 15% of maxillofacial injuries (1,11). The
use of seat belts and airbags has significantly decreased
the incidence of frontal sinus fractures (1,12). The majority of these fractures involve young males (average age 30
years) involved in high-velocity injuries such as motor
vehicle accidents (52%), assaults (26%), and recreation or
industrial accidents (14%) (1,5-6). Greater than 75% of
patients will have associated facial fractures (1, 7). Isolated
anterior table fractures occur approximately 33% of the
time. Combined fractures of the anterior table, posterior
table, and/or the nasofrontal recess account for approximately 67% of frontal sinus injuries. Isolated posterior
table injuries are rare (-2% ofinjuries) (1,4).

DIAGNOSIS
Physical Examination
Due to the high velocity nature of these injuries, associated intracranial, spinal cord, thoracic,. abdominal, and
long bone injuries must be ruled out in all patients. A thorough history and complete head and neck examination
are critical. Common physical findings include forehead
abrasions/lacerations, contour irregularities, tenderness,
paraesthesias, epistaxis, and hematoma. Exploration of
forehead lacerations should be performed with sterile technique, if there is any question of intracranial violation.
Through-and-through injuries of the frontal sinus have a
high morbidity and prompt surgical treatment is indicated.

1255

1256

Section V: Trauma

'---"1---;--

Adult

12 years of age

~'&~~~~~~=t=f== 74 years
years of
of age
age

::...

~abi::P't'-----~-\r---il-- 1 years

of age

)~~~~~;;={3~- 41 years
of age
years of age

(i

1'--7-+----l-1-- 7 years of age

/-~..L--+--1---

12 years of age

r--::;::>.....::::.=---- Adult
Figure 84.1 Fromal sinus development. The anterior ethmoid air
calls invade the fromal bone at age 2. The sinus is fully developed
by age 15. (From AO Surgery Reference Cranial Vault & Skull Base
~.aosu~ry.org. Copyright by AO Foundation, Swiaerland
w1th permJSSJon}.

The presence of associated facial fractures must be ruled

out, with special attention to examination of the o:rbits and
nasoorbitoethmoid complex. Conscious patients should
be questioned regarding the presence of watay rhinorrhea
or salty tasting postnasal drainage suspicious for a cerebrospinal fluid leak. Such :fluid should initially be evaluated
with a halo test" 1he bloody :fluid is allowed to drip onto
filter papa If cerebrospinal fluid is present it will diffuse
faster than blood and result in a dear halo around the
blood. Beta-2 transferrin is the definitive test to confirm
a cerebrospinal fluid leak; howevet;. it is generally a *send
out"' test and may take 5 to 7 days to receive results.

Figure 84.2 Frontal sinus anatomy. The anterior table of the

frontal sinus Is thick bone and provides forehead contour. The
posterior table Is thinner and constitutes a portion of the anterior
cranial fossa. The ftoor or the sinus makes up a portion of the orbital roof. The frontal sinus ostia Is located In the medial, posterior,
and Inferior portion of the sinus floor. (From AO Su~gery Reference
Cranial Vault & Skull Base, www.aosurgery.org. Copyright by AO
Foundation, Switzerland with permission).

Figure 84.3 Frontal sinus drainage. The frontal sinus drainage

pathway has an hourglass configuration with the infundibulum
above and the frontal reca9S below. (From AO Surgery Referenca
Cranial '!'auk & Skull Base, www.aosurgery.org. Copyright by AO
Foundauon, Switzerland with permis9ion).

Radiography
Plain radiographs are oflittle use in the diagnosis of frontal
sinus fradures. A thin cut (1.0 to 1.5 mm.), axial computed
tomography (Cf) scan is the gold standard. It is recommended to obtain coronal, sagittaL and three-dimensional
(3-D) reconstructions for diagnostic accuracy. The axial
imagl!8 are used to evaluate the anterior and posterior tables
(Fig. 84.5); coronal imagl!8 for the sinus floor and orbital
roof (Fig. 84.6). Sagittal images can be useful in assessing
the patency of the frontal recess (Fig. 84.7) (13), while 3-D
reconstructions help define the shap~ location, and orientation of individual bone &.1gments that are seen less
dearly on 2-D views (Fig. 84.8). 1he 3-D infonnation can
reduce the need for swgical dissection, because the sw:gmn
lmowa the number, location, and orientation of 1he Iargu
bone fragments. It can also help the patient and/or family
to understand the bony anatomy and se:mity ofthe injwy.

Figure 84.4 The anterior table of the frontal sinus Is thick cortical bone. It Is more resistant to fracture than any other fadal
bone. (From AO Surgery Reference Cranial Vault & Skull Base,
www.aosurgery.org. Copyright by AO Foundation, Swhzerland
with permission).

Chapter 84: Frontal Sinus Fractures

1257

A.

FiguN 84.5 Mal CT scan demonstrating a frontal sinus fracture involving both the anterior and posterior tables. A: Marked
antarior table di,n~ption. The whhe arrow poinu out a displaced
posterior table bone fragment. 1: Di,ruption of the nasofrontal recess. (From Strong, EB. Frontal sinus fracture': current c:onc:epU.
Cnmiomaxillofac: Trauma Reconstr 2009;2(3):161-175, figure 2.)

TREATMENT ALGORITHM
The appropriate treatment stmtegy for 1he managmtent of
frontal sinus fractures can be made by assessing four anatomic parameters (Fig. 84.9). These parameteiS include
1he presence of: (a) an anterior table fractur~ (b) a posterior table fracture, (c) a nasofrontal l.'eCeM fractur~ (d) a
dural tear (cerebrospinal fluid leak). These findings can be
applied to the algorithm presented to determine appropri.ate treatment (Table 84.1). The treatment options include:
obseiVation, endoscopic repair, open reduction and internal
:fixation, sinus obliteration. sinus cranialization, and rarely

Figure 84.6 Coronal CT scan

de~monmatlng disruption

of
(a"ows). (From Strong, EB.

the ITICidlal orbit: and frontal 1'8CQSS

Frontal sinus fract:ui'CIS: current c:ona~pts. Cranlomsxll/ofac Trauma
Rec:onstr 2009;2(3):161-175, figure~ 3.)

Figure 84.7 Sagittal CT scan demonmatlng a frontal sinus

fracture. The arrow demonstrates naJTOwfng and obstn~ctlon of
the frontal sinus outflow tract. (From Strong, EB. Frontal sinus
fractures: current c:ona~pts. Cranlomsxlllofac Trauma Reconstr
2009;2(3):161-175, figure 4.)

sinus ablation (Reidel procedure).The indications and techniques for each of these procedures are discussed below.

Frontal Recess Fractures

Frontal recess fracwres result in disruption of the sole frontal
sinus outflow tmct (Fig. 84.10 and Table 84.1). Frontal recess

Figure 84.8 3.0 CT scan of a frontal sinus fracture. The 30

rec:onstn~ctlon can be hCIIpful In dellnelltfng the position of bone~

fragments to be locatCid lntraope~nrtive~ly. (From Strong, EB.

Frontal sinus fractures: current concepts. Cr1J1Jiomaxl//oh!c Trauma

Rec:onstr 2009;2(3):161-175, figure 5.)

1258

Section V: Trauma

fradJ.lres that result in sinus outflow obstruction will generally require frontal sinus obliteration. Unfortunately, the
compact anatomy of the frontal recess makes accwate diagnosiJ challenging. One option is to perform a frontal sinus
trephination to visualize the recess endoscopically. This doe~~,
howevet require a general anesthetic. Some authors have
proposed infusion of dye into the sinus to document frontal rea!SS patency. Unfortunately, the passage of dye into the
nose does not oonfirm or refute the presence ofa fracture and
has no documented prognostic value for the ultimate patency
of the frontal recess. Therefore treatment decisions are generally based on thin rut cr scam. If the frontal recess patency
remains in question (and there are no other significant sinus
injuries) patients may be followed with sequential cr scans
at approximately 1 and 12 months to assure that the frontal rea!SS is patent If the frontal recess becomes obstructed
an obliteration is indicated. A more recently described technique involfts obsf!l'fttion of limited frontal sinus fractures
(with serial cr scans), followed by endoscopic frontal sinusotomy for management offrontal recess stenosis ( 14). While

Figure 84.9 Illustration of 1hta anatomic parameters that need

to bta asSCissed whtan dewloplng a trtaatmerrt plan for frontal sinus
fract:urtas. Yeffoll-lntwlor table: Red-posterior table; Bluefrontal rtacess: GrHD-durallrrtCigrlty. (From Strong, EB. Frontal sl
nus fracturtas: current concepts. C,.,nlomax/1/ofac
Reconstr
2009;2(3):161-175, flgure 6.}

r,.,uma

FRONTAL SINUS FRACTURES

FRONTAL SINUS FRACTURES

Anterior Table Fracture---....,.. Nasofrontai . . . . ----!P~o~s~te~r~io~r:....ll~a~b~le~F~r~a~c:!!tu~r~e
...------Recess Injury..... MD

~ No
An'llllrlorwall dl1plecad

YM (> 1-.2mm)

Corrmlnutlon

MW

No(< 1-2mm)

OIMerve

(Add...,.l other

None,
mild or

Endoac:oplc ainu

rnodllrate

(If necaRIIJ'Y}

CSF INk

I~~

Obeen'e

Po...rlorwall dlaplacad

~
-l>'iblwl""l
1(<1toblowl"")

---.....

/"-.. v..

Moderat.
_
to ..............

urg.-y

/
Commhvllon

I \
Mild

Modarata
to..,.,.

CSF leak

''
~

YM

ObaervatiDn

Peralatent
e-7 Oaya

OAIF
YIJ

endcx!CGplc rwpalr
(p...,..,. frontal 1lnU1)

cr.tlallzetlon
frontllll lnu

t---NO

Severe

Oblltenlllt

No

"

obliteration

Chapter 84: Frontal Sinus Fractures

1259

Ostia

Nasofrontal recess

Figure 84.12 Axial CT scan demonstrating a mild to moderately

displaced anterior table fracture. These &actures have a more significant risk of long-tenn aeriletic deformity.

challenging (17-21). The author feels it is not a viable tf!ch.Figure 84.10 Illustration of frontal rec:e!1S mu::tur-the sole
outflow trac::t of the frontal sinus. (From AO Surgery Reference
Cranial Vault & Skull Base, www.uosurgery.org. Copyright by AO
Foundmion, Switzerland with pennission}.

this approach shOW& some promise, it should be resaved for

swgeons with extensive experience in both endoscopic sinus
swgery as well as open approaches to the frontal sinus.

Anterior Table Fractures

Nondisplaced (0 to 2 mm.) anterior table fradJJreS can be
obseJ:ved withlittleriskoflong.term. mo!bidity {Fig. 84.11 and
Tclble 84.1). Fractures with greater displacement (2 to 6 mm)
present little risk of mucocde formation; hawe:m;. the risk of
an aesthetic deformity increases with the degree of displacement (Pig. 84.12). In these situations. the decision for an open
reduction should not be based on the long-term risk of sinu.
iti!lfmuc:xxele formation. Most sinuses will heal adequately.
The decision for swgay should be carefully wdghed against
the :risks of general anesthesia and the long-term iatrogenic
sequelae from a coronal incision (i.e., alopecia. pal'e3thetia!,
facial nm-e injwy, de.). Historically; thete sequelae~ been
downplayed, but they can be more severe than the injury itself.
.Alternatively, minimally invasive approaches may be indicated with mildly displaced fradl.l:l'eJ. 'Iianscutaneous upper
eyelid approachet have been described, but have not gained
significant popularity (15-16). Fn.doscopic fracture reduction
in the arute setting has also been described, but is technically

Figure 84.11 Mal CT scan demonstming a minimally displaced

anterior table frac::ture. These injuries have a low risk of muCOCBie
formmion or aesthetic deformity.

ni.que for the majority of patients. 'Ihe:refon::, if an endoscopic

approach is chosen,. the author prefers a camouflage tf!ch.nique (17,18,20). Surgery for camouflage of the atemal
deformitiet is performed 2 to 3 months after the injury when
all facial swelling has resolved 'Ibis allows the patient to assess
the degree of deformity and make an aco.uate decision as to
whether they desire swgical interllmtion. Patients with thicker
skin are better candidates for this approach because any subde
d.efuds will be more easily camouflaged. If the patient is seen
arutely, the mtionale and indications for a delayed approach
must be dearly explained (ie., risk of iatrogenic injury may
be greater than the traumatic deformity itself); and the patient
must Wldmtand that a fradllre reduction cannot be performed once the fradllre has healed. While the risk of mucocele formation is very low, this should also be discussed. In the
author's experience, many patients with minimally displaced
fractures will desire no swgical intavmtion due to the lack
of significant deformity. More complex: anterior table fractures (greater than 6 mm or with comminution) will likely
require open reduction using a coronal incision (Fig. 84.13).
Uncommonly frontal sinus obliteration may be required
when severe mucosal injuries are present

Posterior Table Fractures

The treatment a)garithm. fur posterior table fractures is complez: due to the risk ofCSF leak, meningitis, and mucocele formation (Thble 84.1) (2,4-7). The primaty decision criteria for
swgical inteivention are the fracwre severity (displacement/

Figure 84.13 Axial CT scan demonstrating a severely displaced

anterior table &acture requiring open reduction and internal
fixation.

1260

Section V: Trauma

FiguN 84.14 Axial CT scan demonstrating a minimally displaced

Uen than 2 mm} posterior (and anterior} table fracture.

conununi1ion) and the presence of a CSF leak While the

degree of displacement that requires swgical intermltion is
"subj~" and contromsiaL the author prdml10 use 2 mm
of displacement as a rule of thumb. Two millimeter is often
verydosetothethicknessoftheposteriortablewhkh.h.asbeen
used by some authors as an indication for intavm.tion (5).

L<s than 2 mm of Displacement: (Fig. 84.14)

Patients with posterior table displacement less than 2 mm,
and no CSF leak, may be observed. Long-term follow-up
with repeat cr scans at 1 month and 1 year is appropriate
to rule out mucocele formation. If a CSF leak is praent
at the time of injury, 1 Wf!f!k of observation ia indicated;
approximately SO% will resolve spontaneously ( 6). If the
leak ia persistent, open reduction, dural rep~ and sinus
obliteration are indicated.

Greater than 2 mm of Displacement: (Fig. 84.15)

Patients with posterior table displacement greater than
2 mm, no CSF leak, and mild comminution should be
treated with sinus obliteration. More severe injuria, with a
frank CSF leak and modemte to severe comminution, will
li1rely require remcmd ofsome posterior table bone 10 repair
the dural teat: If the injury or surgical repair results in disruption of more than 25% to 30% of the posterior table, sinus
cmnialization should also be considered {Fig. 84.16) (22).

SURGICAL TECHNIQUE

Frontal Sinus Trephination

'Ii'ephination and endoscopic visualization of the frontal
sinus can be useful to assess the frontal recas as well as the
extent of any posterior table injw:y. After infiltration oflocal

FiguN 84.16 Axial CT scan demonstrating a severely displaced

and comminuted fracture of the posterior (and anterior) table.

anesthesia. a 1.0 10 1.5 em skin incision is placed midway

between the medial canthus and the glabella. approximately
1 an inferior to the brow (Fig. 84.17). 1he incision is best
hidden by placing it inferior and deep to the cw:ve of the
forehead A small "V" shaped relaxing incision may be added
to redUCE the risk of scar contmcture and webbing. The incision should NOT be placed within the eyebrow, because it
may result in alopecia. and place the supratrochlear neurovasOJiar pedicle at risk. A guarded micro-point, monopolar
electrocautery can then be used to dissect through the soft
tissues and onto the frontal bone. 1he location and depth
of the sinus should be confirmed on the cr scan or with
intraoperative navigation. A depth of at least 7 mm ia recommended to avoid injuring the posterior table. A small
cutting burr is used to open a 4 to 5 mm frontal sinusotomy
(F'tg. 84.17 inset). The mucosa is incised and the sinw can
be sudi.oned free of any blood or mucous. A 30 degrees
endoscope is used to examine the posterior table and frontal recess for any evidence ofinjw:y. A Valsalva manf!lM7 can
assist with the diagnosia of a CSF leak (Fig. 84.18). While
flexible pediatric bronchoscopes are more rumbe:rsome,
they can be used 10 examine the lateral aspects of the sinw.
Once the examination has been completed. the skin and
soft tissue are closed metiOJiously in layers.

~~'~ jj~

)0\
FiguN 84.15 Axial CT scan demonstming a moderately displacad (greater than 2 mm} posterior (and anterior) table &acture.

FiguN 84.17 Illustration demonstrating the incision for a frontal sinus trephination. The incision should be midway between
the medial canthus and the glabella, and approximately 1 em inferior to the brow. The incision is ben hidden when placed inferior
to the forehead curvature. Inset: A small o.ming burr is used to
trephinate the sinus taking care to avoid injury to the posterior
table. (From Strong, EB. Frontal sinus fracwres: current CJOncapts.
Craniomaxillofac: Trauma ReCDMfT 2009;2(3):161-175, figure 9.)

Chapter 84: Frontal Sinus Fractures

endoscope

incision

1261

Figure 84.19 Illustration demonstrating the Incision used for the

endoscopic approach to an anterior table frontal sinus fract'Ure.
The "working Incision Is placed directly above the fract'Ure, while
the "endoscope" Incision Is plac:rad approximately 4 em medial.
Both Incisions are placed 3 em above the hairline. (From Sttong,
EB. Frontal sinus fractures: current conc:rapt:s. Cntnlomaxlllofac
Trauma Reconstr2009;2(3):161-175, flgure 10.)

Figure 84.18 Endoscopic vlcm of the frontal sinus using a

30.degree endoscope. A Valsalva maneuver Is perfonned to dem
onstrateleakage of CSF through a posterior table fracture.

Endoscopic Antwior Table Repair

nus technique is appropriate for isolated anterior table :frac111I'e8 above the oibital rim. Several authors ~ described
endoscopic reduction ofthese fractures; howe-rer, the author
:finds this to be technically challenging (19-21). the repair
described below is a camouflage technique. It is performed
approximately 2 to 4 months after the injury when all forehead swelling has resolved and an accurate asse\lsment of
the deformity can be made. Prior to swge:ry, appropriate
consent is obtained for the procedure including the risks of
bleeding, infection, paraesthesias, alopecia. poor aesthetic
result. and possible need for open approach if an endoscopic repair cannot be performed. The surgical technique
is similar to a brow lift and uses the same instrumentation
(23). Local vasoconstriction agents should be used liberally to minimize the need for electrocaute:Jy, and reduce the
risk of alopecia at the incision site. A 3 to 5 an parasagittal
"working" incision should be placed above the :fract:JJre. 3 an
behind the hair line. and carried tluough. the periosteum
onto bone (Pig. 84.19). 1he acwallength will vary depending on the size of the fracture and implant to be inserted. A
1 to 2 em subperiosteal ..endoscope" incision is then placed
at the same height, 4 an medial to the working incision. In
patients with a prominent forehead or receding hair line. the
incisions may need to be moved closer to the hairline. allowing visualization around the forehead curvawre.
The initial subperiosteal elevation is carried down to the
level of the fradllre using an endoscopic brow lift elevator.
The dissedion is mpid and does not require the use of the

endoscope (Fig. 84.20). Caution should be used to maintain

the integrity of the periosteal envelope. Tean in the periosteum will "catch" the endoscope when it is inserted and maJre
visualization more difficult A 4.0 mm, 30-degree endoscope
(with a rigid endosheathand camera) is then inserted through
the endoSCDpe incision. A huge endosheath guani helps to
maintain a generous optical cavity (Fig. 84.21). Dissection
over the fradllre is then caDi.ed out under direct visualization.
A fibrous scar layer prevents entty into the sinus (Fig. 84.22).
The supraoibital and supratrochlear neurovascular pedides
are oommonly visualized at the oibital rim. Excessive traction
on the pedides should be avoided as it can result in postopemm paresthesias. Once the limits of the fracture ~
been visualized,. a 0.85 mm thick porous polydh:ylene sheet
is trimmed to approximate the defect (using the depression
in the forehead skin as a template) (F'tg. 84.23).1he superior
edge of the implant is m.a:rked with a pen to maintain the
orientation endoscopically during insertion. The implant is

Figure 84.20 Illustration of a subperiosteal dissection used for

elCpOSUre of an anterior table fracture. The Initial dissection Is CIJI'rled down to the level of the fracture using external palpation to
define the limits of dissection. An endoscope Is not used. (From
AO Surgery Reference Cranial Vault & Skull Base, www.aosurgery.
org. Copyright by AO Foundation, Switzerland with permission).

1262

Section V: Trauma

Endosheath

FiguN 84.21 Illustration of a 3Cklegree endoscope and a rigid

endosheath with a large tip guard to maintain U:te integrity of the
periosteal envelope and op\ical cavity. (From AO Surgery Referenca
Cranial Vault Bt Skull Base, www.aosurgery.org. Copyright by AO
FoundErtion, Switzerland with permission).

inserted through. the wolking incision and manipulated both

intmlally (with instruments) and extmially {with fingers)
CM!f the defect (Fig. 84.24). Once the implant is in pla~ the
size and shape are evaluated endoscopically and the implant
is removed. trimmed. and refined. 1he process is repeated
until the diameter of the implant is approximately 2.0 to
3.0 mm I~ than the defect If necfS.llary for stability, the
implant can be sutured together in two to three layem as an
in:vmed pyramid shape to more aco.uately fill deeper defects
(Fig. 84.25). Patimts with vexy thin skin may require a smaller
implant that sits Bush within the defect. Once the implant is
appropriately fashioned. a 25 gauge needle is passed through
the skin am- the fmc:IJ.lre and endoscopially visualized to
detmnine the best site for a percutaneous incision and screw
placement. Optimal incision placement will allow screws to
be placed on either side of the implant through a single incision (Fig. 84.26). Haw~ some larger implants may require
two separate stab incisions. Once the site has been determined, a no. 11 blade is used to make a 2 mm, through-andthrough stab incision. A small self-drilling screw (4 to 7 mm

Figure 84.22 Illustration of the endoscopic exposure of an an

terior table frontal sinus fracture. A fibrous scar layer prevents
entry Into the sinus. (From AO Surgery Ref'er.~nce Cranial Vault
& Skull Base, www.aosurgery.org. Copyright by AO Foundation,
Switzerland with permission).

FiguN 84.23 A 0.85 mm thick sheet of porous polyethylene

sheeting is placed on the skin over the defect and used as a tem
plate to approximate the size of the implant to be used. (From AO
Surgery Referenca Cranial Vault Bt Skull Base, www.aosurgery.org.
Copyright by AO Foundation, Switzerland with permission).

in length) is passed through the stab incision, through the

edge of the implant (at least 1 mm from the edge to avoid
tearing of the implant), and into stable bone at the periphery of the fracture (Pig. 84.27). 1he screw must be securely
attached to avoid dislodging it from the saewdri.w:r as it
passes through the soft ti8sue. If the implant remairul unstable after the fi:mt screw is placed. a second screw is applied on
the contralateral side. lhe scalp incisions are then dosed in
layers and a pressure dressing is applied.

Open Reduction and lntel'nal Fixation

.Anterior table fractures that cannot be observed or managed
endoscopically may require open reduction and internal
fixation. lhe patient consent should include the risb of
bleeding, infection, paresthesia, headache. CSF leak. orbital

Figure 84.24 Once the Implant has belen trimmed to size, the su
perlor edge Is marked to maintain orientation af<r Insertion. The
Implant Is then Inserted through the working lndslon under dir.~ct
visualization with the endoscope. (From AO Surgery Refer.~nce
Cranial Vault & Skull Base, www.aosurgery.org. Copyright by AO
Foundation, Switzerland with permission).

Chapter 84: Frontal Sinus Fractures

1263

Figure 84.25 The Implant may be layered and sutur.~d together

for gr.~ater stability In deepc~r defects. (From AO Surgery Reference
Cranial Vault & Skull BaSQ, www.aosurgery.org. Copyright by AO
Foundation, Switzerland with permission).

injury, diplopia, meningitis, external deformity, and late

mucoceleformation. In theoperatingroom, thebedis wmed
180 degrees away from the anesthesiologist and corneal
shields ortemporarytarsonhaphies are placed. The hair need
not be shaved. but patients with longl:f hairwill require banding to delineate the incision line (Fig. 84.28). Application of
a water-based lubricant to the hair facilitates separating the
hair and rapid application of the rubber bands. SWgical towels are stapled to the scalp just behind the incision line. An
adherent plastic suction pouch is applied at the leading edge
of the towel to collect blood and minimize spillage
The greatest blood loss oc:cun with the initial incision
and wound closure. When possible, generous amounts of a
vasoconstrictor agent should be injected in a subgaleal plane
prior to SUigf!IY. In patients who will wear their hair longu
than 3 to 4 em. the author prefers a zig-zag" incision. starting behind the ear and running 4 to 6 an behind the hair line
(Fig. 84.29). Postoperatively when the patient ia upright,.
the zig-zag pattern allows gravity to pull the hair inferiorly,

Figure 84.27 A SQifdrllllng screw Is passed through the edge~

of the! Implant and Into stable bone. (From AO Surge~ry Reference
Cranial Vault & Skull BaSCI, www.aosurge~ry.org. Copyright by AO
Foundation, Switzerland with permission).

covering the transverse arms of the sau:: Excessive trauma

"tips"' of the zig-zag incision should be avoided, u it
may increase the risk of alopecia. If the patient weau vecy
short hail;. a zig-zag pattern only lengthens and accentuates
the incision. In this situation. a traditional straight line incision (with a central widow's peak" or a methylene blue tattoo for realignment) is more rapid and provides adequate
cosmesis (Pig. 84.30). In patients with male pattern baldness, the inruion can be moved posteriorly to camouflage
it within in the hair. This will necessitate a slightly more
extensive lateral dissection to allow fotward rotation of the
scalp flap . .All hair-bearing skin should be handled carefully,
to avoid postoperative alopecia. While forehead laceratiom
can be used to assiat with the rep~ midforehead. brow,
and "gull wing incisions should be avoided due to the
prominent scar and associated forehead paresthesiu.
to the

Figure 84.26 Illustration de~plctlng 1he1 location of the stab

Incision USCid for lnSQrtfon of a fixation screw to stabilize 1he lm
plant. A 25 gauge needle~ Is passed 1hrough the skin and visual
lzed Internally. The Ideal location allows for a screw to be plaa~d
on e~lther side of 1he Implant through one stab Incision. (From AO
Surgery Reference Cranial Vault & Skull Base, www.aosurgery.org.
Copyright by AO Foundation, Swftze~rland with pe~rmission).

Figure 84.28 Photograph of banding hair to kMp It away

from the Incision. (From AO Surge~ry Refere~nc:a Cranial Vault &
Skull Base, www.aosurge~ry.org. Copyright by AO Foundation,
SwltzCirland with pe~rmlsslon).

1264

Section V: Trauma

perkndum
temporalis musdt

tempcwalls. muscle- f.asda

p~rotidgland

Figure 84.31 Illustration of a coronallndslon In the temporal region. (From Strong, EB. Frontal sinus fractures: current concepts.
CranlomaxJIIofsc: Traum Rec:onstr2009;2(3):161-175, figure 15.)
FiguN 84.29 Photograph of a zig-zag coronal incision.
(From Strong, EB. Frontal sinus fractures: current concepts.
Craniomaxillofac: Trauma Reco119tr 2009;2(3}:161-175, figure 14A.)

The salp is opened in thirds. This allows dme to control

ofbleeding and minimize blood loss. The centtal one-third
(temporal line to temporal line) is initially incised down to
the level of the galea aponeurosis. Electroalutely is avoided
to protect the hair follicles. Lalger wssels should be ued oH
individually. If necessaJY, Raney dips may be applied judiciously, depending on swgeon preference. Double-pronged
skin hoob are used to retract the scalp a:MJ:1f from the skull
and protect the underlying pericranium. Once the galea

FiguN 84.30 Photograph of a straight line incision with a

widows peak at the top for alignment and wound dosure.
(From Strong, EB. Frontal sinus fractures: current concepts.
Craniomaxillofac: Trauma Reco119tr 2009;2(3}:161-175, figure 148.)

aponeurosis is incised, air will rapidly enter into the subgaleal

space, developing an excellent dissection plane just above the
pericranium. If there is a need for use of the pericranial flap
during the sw:gical rep~ the pericranium is left intact on the
calvarium. It is more readily separated from the scalp when it
is left attached to the bone. Ifthere is no need for a pericranial
flap, it is incised and elevated in one layer with the salp.
Next. the lateral thirds ofthe scalp are individually incised.
This dissection demands a thorough. understanding of temporal anatomy (Fig. 84.31). The incision is extended from
the temporal line inferiorly behind the helix (Figs. 84.29
and 84.30). The retroauriailar incision is easily extended
inferiorly behind the ear as ~essary for flap rotation. while
remaining completely hidden. A preauriOJlar incision offers
no real advantage, and results in a visible sau: The temporal
incision should then be carried through. the temporoparietal
fascia (superficial temporal fascia) and onto the temporalis
muscle fascia (deep temporal fascia), ~ing the temporal
artery and vein. which can be controlled using a suture ligature or bipolar cautery. The appropriate level of dissection
can be confirmed by placing a small (1 to 2 mm) nick in the
temporalis muscle fascia, exposing dark temporalis muscle
beneath. the flap is then elevated anteriorly using blunt
fingu dissection or gaU'l".E'. with limited use of the scalpel.
The integrity of the temporoparietal fascia must be maintained. as it contains the frontal branch. of the facial ner:ve
(Pig. 84.31) . .As the temporal flap is elevated, it is joined with
the central dissection that was performed initially. The fibers
along the temporal line are incised sharply.
If the posterior table of the frontal sinus is intact and the
surgeon has left the pericranial flap attached to the galea
aponeurosis, the central dissection is carried forward in a
subperiosteal plane using a wide elevator. The dissection is
cani.ed around the fi:acture taking care to protect the integrity of the bone fi:agments when possible. .As the supraorbital rims are reached, care is taken to avoid injwy to the

Chapter 84: Frontal Sinus Fractures

Figure 84.32 Illustration depicting 1he supratrochlear neurovascular pedicle after being removed from 1he supraorbitul fissure with an
O$t&OtOme. This provides &JCPOSUre to 1he entire orbital roof. (From
AO Surgery Referenc:& Cranial Vault & Skull Base, www.aosurgery.
org. Copyright by AO Foundation, Switzerland with permission).

supraoibital and supratrochlear neurovascular pedicle~.

If greater exposure is required, the dissection can be carried
around the OJbital rims into the orbits. The suprao:rbital
neurova.sallar pedicle can be released, if necessary, using a
small osteotome placed at the medial and lateral aspect of
the foramina and down-fraewring the bone (Pig. 84.32).
Once the pedicle is released, a careful dissection following
the internal concavity of the superior orbit will avoid violation of the orbital periosteum and prolapse of orbital fat
If the periosteum has been maintained on the calvarium,
the soft tissue dissection is generallycarried to the level ofthe
orbital rims, while attempting to protect the integrity of the
pericranium over the fracwre site. .A1 this point. the pericranial flap is incised and elevated off the calvarium down
to the level of the orbital rims. lateral incisiom are placed
2 em cephalad to the temporal line (Fig. 84.33). Ifnecessar:y,

1265

Figure 84.34 Photograph of a large pericranial flap harvested

for repair of a dural defect. (From Strong, EB. Fromal sinus fractures. Oper Tech Otofaryngo/2008;19(2):151-160, figure 10)

2 to 4 an of extra length can be obtained by joining the

lateral periosteal incisiom behind the initial skin incision.
As the dissection is carried inferiorly, periosteallaceratiom
may be noted at the fracture site. A careful dissection will
usually maintain an intact vascular supply and provide a
lengthy :flap that can be used for repair of CSF leab or obliteration of the sinus itself if it is small (Ftg. 84.34).
Reduction of noncomminuted fractures can be extremely
challenging. When the convex surface of the frontal bone
fractures, it goes through a compression phase, before
becoming concave (Pig. 84.35). Fracwre reduction requires
enough force to pull the bone fragments back through the
compression phase (Fig. 84.36). It may be neassar:y to
FORCE

I
FORCE

Figure 84.33 Illustration showing elevation of a large pericranial flap. (From Strong, EB. Fromal sinus fractures. Oper Ter:h
Otolaryngol 2008;19(2):151-160, figure 9)

Figure 84.35 Illustration of 1he fol'CIIIS on the frontal bone when

a frontal sinus fracture oc:c:urs. Note that as the bone goes from
convex to concave that there is a compressive phase the bone must
pass 1hrough. (From Strong, EB. Frontal sinus fractures: curntnt
concepts. Craniomaxillofac Ttlluma Reco11Str 2009;2(3}:161-175,
figure 17A.)

1266

Section V: Trauma

FORCE

FORCE

Figure 84.38 Any bone fragmcants that are rcamoved should be

FORCE

FiguN 84.36 Illustration of the forces that must be applied to

return the frontal bone in order to reduce a fracture. Note that as
the bone goes from concave to convex_ it must pass through the
same compressive phase seen during fracture. This may require
the surgeon to apply significant amount of force or remove a bone
segment to release the pressure. (From Strong, EB. Frontal sinus
fractures: current conceptS. Crllniomaxi/lofac Tn~Yma Reconstr
2009;2(3):161-175, figure 178.}

remove a bone fragment to release the tension and reduce the

fracture. If comminution exists or bone segments overlap, a
small bone hook may be insinuated between the fragments
to assist with elevation. Another technique is to place a 1.5 to
2.0 mm screw in the depressed segment, grasp the screw with
a heavy hemostat. and pull upward (with controlled force) to
reduce the bone fragments (Ftg. 84.37). Once the bone fragments are mobilized, the sinus mucosa should be evaluated.
A 30-degree endoscope can be helpful to visualize the sinus
and the nasofrontal m:ess through a limited bone defect
E~ attempt should be made to keep the majority of the
fragments in place. allowing for a more accurate repaii: If
bone fragments are removed, aaanging them atop a drawing

Figure 84.37 Illustration of a bone~ screw to assist \'\lith fracture~

reduction. (From AO Surgcary RCifcarcane Cranial Vault & Skull Base,
www.aosurgcary.org. Copyright by AO Foundation, Swftrerland
with permission}.

kcapt moist atop a drawing of the fracture~. This will help maintain
anatomic orlcantatlon for the~ final reconstruction. (From AO
Surgery Referenaa Cranial Vault & Skull BaSCI, www.aosurgery.org.
Copyright by AO Foundation, Swftrerland with permission}.
the~

of the fracture helps to maintain the anatomic orientation

for the final reconstruction (Fig. 84.38). 1he fracture is then
reduced and plated with 1.0 to 1.3 microplates. Small gaps
(4 to 10 mm) can be reconstructed with titanium mesh.
Hydroxyapatite bone cement should not be used to fill
bone defects. It has an unacceptably high-risk infection and
emusion. During wound closllR'. it is important to resuspend the temporal soft tissues to avoid long-term ptosia of
the forehead and upper midface. Two, 2-0, monofilament
sutures are passed through the temporoparietal fasda and
suspended up to the temporalia muscle fusda (Fig. 84.39).

Frontal Sinus Obliteration

More severe injuries may require frontal sinus obliteration.
A coronal incision is used to expose the fracture as previously described. A pericranial flap should be maintained for
any unanticipated injuries that might be found intraoperatively (CSF leak, dural tea!;. etc.). After complete exposure of

Figure 84.39 Photograph demonstnrtfng rcasuspcanslon of the

coronal flap to the tCimporalls muscle fascia. (From Strong, EB.
Frontal sinus fractures: current conceptS. Cnmlomaxlllofsc Trauma
Reconstr 2009;2(3):161-175, flgure 18.}

1267

Chapter 84: Frontal Sinus Fractures

. ~~
p -~- ....... l:]
_ .:
~

-. . , I

, ...... ~

, ..

. . .. ...

... ~.,

...

Figure 84.40 Illustration dclplctlng the use of a bipolar forceps to outline the bordlo!rs of 1ftea frontal sinus In preparation for
a completfon frontal sinusotomy. (From AO Surgery Reference
Cranial Vault & Skull BaSCI, www.aosurgery.org. Copyright by AO
Foundation, SwltZtilrland with permission).

the frontal bone, all anterior table fragments should be carefully removed, kept moist on a side table, and oriented on a
dmwing to assist with the final repair (Fig. 84.38). In some
instances, it may be necessary to perform. a frontal sinu
otomy to remove the remaining anterior table bone and
visualize the entire sinus cavity. Localization of the sinu
otomy cuts can be performed in several ways. Historically a
"6 foot penny Caldwell" x-ray was used (i.e., anterior-~
terior Caldwell x-ray with the patient placed 6 feet from the
x-ray tube). H~ CUJTf!nt digital radiograph teclmology
has made these films very difficult to obtain. Inttaoperative
navigation is effective but requires a specialized scan and
navigational hardware. Altcmatively, one tine of a bipolar
cautery can be placed through a defect in the frontal bone,
while the opposite tine remains visible outside the sinus.
The intemal tine is then walked around the periphery of
the sinus, while the outer tine is used to mark an outline the

Figure 84.42 Illustration depleting preappl!catlon of mlcroplatCis spanning thCI proposed ostCiotomy linea, prior to completion frontal sinusotomy. (From AO Surgeary RCifearence Cranial Vault
& Skull BaSCI, www.aosurgcary.org. Copyright by AO Foundation,
SwltzCirland with pcarmlsslon).

sinus with a drill or ink (F"tg. 84.40). Another technique

involves insertion of a light source into the sinus through a
fmcture line; this ttansilluminates the periphecy ofthe sinus
and guides the osteotomy (Fig. 84.41).
After the limits of the sinus have been marked out, two
to three microplates (1.0 to 1.3 mm) are "pre-applied"
spanning the proposed osteotomy sight (Fig. 84.42). This
allows the swgeon to accurately reposition the osteotomized bone even after it is removed. The plates are then
rotated superiorly away from the osteotomy, with one
screw left in place (Fig. 84.43). A drill is used to postage stamp perforations around the periphery of the sinus
(Fig. 84.44). It is angled toward the sinus cavity to avoid
intracranial penettation (Fig. 84.45). A side-cutting burr
is then used to join the perforations and complete the
osteotomy (Fig. 84.46). Care should be taken to avoid
disruption of the predrilled miniplate holes while performing the osteotomy. Inferiorly, the orbital rims are

~..

;
..

, -- -

Figure 84.41 Illustration deaplctlng the use of a light source to

transilluminate the bordears of thea frontal sinus In preparation for
a completfon frontal sinusotomy. (From AO Surgery Reference
Cranial Vault & Skull BaSCI, www.aosurgery.org. Copyright by AO
Foundation, SwltzCirland with pcarmlsslon).

.e . . ...

;
~ ..

" ..

-;
,

'.....

,
,.

.....

' e '.

Figure 84.43 Illustration deaplctlng rotation of thCI mlnlplates to

allow for ostCiotomy. (From AO Surgeary RCifearence Cranial Vault
& Skull Base, www.aosurgeary.org. Copyright by AO Foundation,
Switzerland with pcarmlsslon).

1268

Section V: Trauma

Figure 84.44 Illustration depleting "postage stamp perforatIng osteotomies to outline the slnus. (From AO Surgery Reference
Cranial Vault & Skull Baw, www.aosurgery.org. Copyright by AO
Foundllt:lon, Switzerland with permlsslon).

Figure 84A6 Illustration of side-cutting burr uwd for comple

tlon frontal sinusotomy. (From AO Surgery Reference Cranial Vault
& Skull Base, www.aosurgery.org. Copyright by AO Foundation,
Switzerland wlth permission).

osteotomized at the periphery of the sinus. The glabella

is osteotomized approximately 5 mm. above the junction
with the nasal bones. No osteotomy is placed in the orbital
roof. Particular attention must be paid to avoid injury to
the suprao:rbitalfsupratrochlear nf!UI'OVUcular pedicles.
A cw:ved 4-mm osteotome (curved away from the posterior table) is then inserted into the sinus from above, and
used to fracture the intersinus septum (Fig. 84.47). Finally,
a hand is placed on the anterior table and the osteotome is
gently elevated to out fracture the anterior table.
Once the sinus is completely exposed, the posterior
table integrltr is evaluated. If the bone ia stable and free
of significant defects, sinus obliteration is acceptable.
However;. all sinus mucosa must be meticulously removed
from the entire sinus, including the anterior table bone.
Initially a 4 to 6 mm cutting burr is used, followed by a 1 to
4 mm diamond burr for the periphery of the sinus. Access
to the deepest portions of the sinus can be challenging,

and particular attention must be paid to the scalloped

areas above the o:rbits and at the periphery of the sinus
(Fig. 84.48). After complete removal of the sinus mucosa,
attention is turned to the frontal recess. The mucosa of the
frontal sinus infundibulum is elevated and inverted inferiorly occluding the ostia. A small plug of temporalis muscle
is then placed above the inverted mucosa. A slulrp 5 mm
osteotome is then used to obtain two 5 x 5 mm bone chips
from the calvarium (Fig. 84.49). These are inserted to block
the frontal sinus infundibulum (Fig. 84.50).
Many different autologous materials havebeen successfully
used for sinus obliteration. These include abdominal fat. cancellous bonf:, muscle. pericranium, and spontaneous ~
neogenesis with auto-obliteration (2,6,7). While different
authoiS may advocate a specific material having the ~est
success rate in their hands (or at their institution), the success rate is more likely related to the complete removal of all
sinus mucosa and meticulous attention to swgical technique

Figure 84.45 Illustration depleting 1he approprlllt:e angle of

approach to safely enter the frontal slnus and avoid violation of
the posterior table. (From AO Surgery Reference Cranial Vault
& Skull Baw, www.aosurgery.org. Copyright by AO Foundation,
Switzerland with permlsslon).

Figure 84.47 Illustration of curwd osteotome used to fracture the

lnterslnus wptum and releaw 1he osteotomlzed frontal bone. (From
AO Surgery Reference Cranial Vault & Skull Base, www.aosurgery.
org. Copyright by AO Foundation, Switzerland wlth permission).

Chapter 84: Frontal Sinus Fractures

Figure 84A8 Complete removal of the &ontul sinus mucosa is

imperative to successful sinus obliteration. The areas above the
orbits and at the periphery of the sinus o.e., darkened areas) require
special attemion as they are more difficult to visualize. (From AO
Surgery Raferenat Cranial Vault 8r. Skull Base, www.aosurgery.org.
Copyright by AO Foundation, Switzerland with permission).

rather than the type of autologous material used for obliteration. OveralL the success rates are quite high. but there
is always small risk of late mucocele formation. 1he author
prdm abdominal felt Alloplastic marerials, such as hydroxyapatite bone cement, should be avoided due to the mk of
infection and extrusion. A fat graft is obtained through a left
lower quadrant (or periumbilical) incision using a separate,
sterile instrument set The fat graft should be harverted in a
single piece if possible, without the use of electrocautery. The
felt graft is then inserted into the sinus cavity and trimmed to
size The anterior table fragments are replaced. Anterior table
stabilization and wound closure are completed as described
above under dosed reduction.

Frontal Sinus Cranialization

The most severe injuries result in disruption of the posterior table. Consultation with a neurosurgical colleague

Figure 84.49 Illustration of outer table bone graft harvested

from the parietal region. Note the bone graft Is taken at a location
where the periosteum remains Intact. (From AO Surgery Reference
Cranial Vault 8r. Skull Base, www.aosurgery.org. Copyright by AO
Foundation, Switzerland with permission).

1269

F'.gwe 84.50 lllust:ra\ion of an out table calvarial bone graft placed

into the &ental recess to isolate the sinus from the nasal cavity. (From
AO Surgery Refarenc:e Cranial Vault 8r. Skull Base, www.acsurgery.
org. Copyright by AO Foundation, Switzerland with permission).

is recommended. While the exact indications for cranialization of the sinus can be controversial, injuries that: (a)
disrupt greater than 25% to 30% of the posterior table
wall, (b) result in significant comminution and instability of the posterior table, and/or (c) require repair
of a large dural laceration should be considered for cranialization. The surgical approach is described above
(see "Frontal Sinus Obliteration). It does not require
a craniotomy and can be performed through the sinus
itself. Howeve~;. maintaining the integrity of the pericranial ftap becomes more critical for dural repair and
control of CSF leaks. All free bone fragments from the
anterior and posterior table are removed. Fragments that
are adherent to the dura should be freed with Penfield
elevators (Fig. 84.51). The dura is then elevated from
behind any stable bone at the periphery of the sinus and
retracted with malleable brain retractors. Kerrison rongems are used to remove any remaining posterior table

Figure 84.51 Illustration of dural elevation prior to removal of po5<

tarior table bone for a &ental sinus cranlallzatlon prooadure. (From
AO Surgery Refanii'IC8 Cranial Vault 8r. Skull Base, www.aosurgary.org.
Copyright by AO Foundation, Swftzarland with permission).

1270

Section V: Trauma

SUMMARY

FiguN 84.52 Illustration of bone removal with Kerrison rongeurs. The entire posterior table should be removed to complete the frontal sinus aanialization. (From AO Surgery Reference
Cranial Vault & Skull Base, www.aosurgery.org. Copyright by AO
Foundation, Switzerland with pennission).

bone (Fig. 84.52). A drill should be used to smooth the

posterior table edge flush with the anterior sinus walls,
floor, and anterior cranial fossa (Fig. 84.53). The frontal recess is occluded as previously described in "Frontal
Sinus Obliteration... Simple dural lacerations can be
repaired with interrupted 5-0 nylon sutures. More complex injuries may require neurosurgical debridement
and closure with a pericranial flap. When a pericranial
flap is used,. a small bony defect must be fashioned just
above the o:rbital rims to allow passage of the flap intracranially without strangulating it. The anterior table
is then reconstructed using 1.0 to 1.3 microplates and
mesh. The bony disruption of the anterior table can be
so severe that posterior table fragments are required for
reconstruction. The incision is dosed as described under
"Open Reduction and Internal Fixation.

Optimal management of frontal sinus fractures remains a

con1I'CJVmlial topic. While there is a paucity of evidence to
support a unifoim approach to treatment, it is critical that
each surgeon have a well thought out strategy for management of these injuries. 1he author provides an anatomically
based. hieran::hical treatment stmtegy for frontal sinus fractures. Differences in materials use for reconstruction, obliteration, or cranialization of the sinus are likely less important
to a successful outcome than meticulous surgical technique. There is a long-term risk of mucocele formation in
all patients sustaining frontal sinus fractures, even years after
treatment. Patients must therefore be informed of this risk,
educated about the signs and symptoms of a mucocele. and
encouragl:d to actively participate in long-term follow-up.

1he majority of frontal sinus fractures imolve young

males (~age 30 }"2DD) involved in high ~ocity
injuries such aa motor~eacx:idents (52%), assaults
(26%), and recreation orindusttial accidents (14%).
A thorough history and physical examination is ai.tical for patients with frontal sinus fractures. The major-

Figure 84.53 Illustration of a drill used to remove the remainIng posterior table bone ftush with the arru~rior aanlal fossa.
A malleable should be used to fli'Ot'lct the brain. (From AO
Surgery Reference Cranial Vault & Skull Base, www.aosurgery.org.
Copyright by AO Foundation, Switzerland with permission).

ity of patients will have aasociated facial fractures and

commonly have other non-head and neck injuries.
1he hierarchy of swgical management for frontal
sinus fractures includes: management of any intracranial injury, avoidance of short- and long-term
complications such as mucoceles, reestablishment
of an aesthetic facial con~ and return of normal
sinus function if possible.
1he gold standard for diagnosis is a thin cut (1.0 to
1.5 mm), axial cr scan with coronal, sagittal, and
3-D reconstructions.
1he appropriate treatment strategy for the management of frontal sinus frac:ture8 can be made by
uaessing fouT anatomic parameters. These parameters include the presence of (a) an anterior table
fracture.. (b) a posterior table fracture.. (c) a nas~
frontal recess fracture, (d) a dural tear (cerebrospinal
fluid leak).
Nondisplaced (0 to2 mm) anteriortablefracturescan
be obaened with little risk of long-term mo:rbidity.
Coronal indaions cany with them a moderate risk
of alopecia. When recommending a coronal incision for mildly displaced fracture (2 to 6 mm), the
risk of alopecia must be weighed against the risk of
a cosmetic deformity if nothing is done.
Patients with mildly displaced anterior table fractures
that do not extend into the inferior o:rbital rim are
potential candidatea for endOBCOpic fmclure treatment.

Chapter 84: Frontal Sinus Fractures

Posterior table fractures are the result of higher

velocity injuries and carry with them greater risk of
long-term complications.
If sinus obliteration is to be performed, it is absolutely critical that all sinus mucosa be meticulously
removed to avoid long-term mucocele formation.
Because mucoceles form very slowly, it is critical
that the patient be informed of the associated symptoms, and that long-term follow-up is stressed.

REFERENCES
1. Strong EB, Pahlavan N, Saito D. Frontal sinus fractures: a 28-year
retrospective review. Otolalf'llgol Head Neck Surg 2006;135(5):
774-779.
2. Rodriguez ED, Stanwix MG, Nam AJ, et al. 1\venty-six-year experience treating frontal sinus fractures: a novel algorithm based
on anatomical fracture pattern and failure of conventional techniques. Plast Reconltr Surg 2008; 122(6): 1850-1866.
3. Strong EB. Frontal sinus fractures: current concepts.
Craniomaxillofac 'ITauma Reconstruct 2009;2: 161-176.
4. Papel ID. Facial plastic and reconsi1Uctive surgery, 3rd ed. New York
Thieme. 2009.
5. McGraw-Wall B. Frontal sinus fractures. Facial Plast Surg 1998;
14(1):59-66.
6. Rohrich RJ, Hollier LH. Management of frontal sinus fractures.
Changing concepts. Oin Plast Surg 1992;19(1):219-232.
7. Wallis A. Donald PJ. Frontal sinus fractures: a review of 72 cases.
Laryngoscope 1988;98(6 Pt 1):593-598.
8. Bell RB, Dierks EJ, Brar P, et al. A protocol for the management
of frontal sinus fractures emphasizing sinus preservation. J Oral
Maxillofoc Surg 2007;65(5):825-839.
9. Anon JB, Rontal M. Zinreich SJ. Anatomy of tM paranasal sinuses.
NewYork:Th.ieme. 1996.

1271

10. Stammberger HR. Kennedy DW. Paranasal sinuses:anatomic terminology and nomenclature. The Anatomic Terminology Group.
Ann Otol Rhinol Laryngol Suppl1995;167:7-16.
11. Nahum AM. lhe biomechanics of maxillofacial trauma. Oin
Plast Surg 1975;2(1):59-64.
12. Rontal ML. State of the art in craniomaxillofacial trauma: frontal sinus. Curr Opin Otolaryngol Head Neck Surg 2008;16(4):
381-386.
13. Jain SA. Manchio JV. Weinzweig J. Role of the sagittal view of
computed tomography in evaluation of the nasofrontal ducts in
frontal sinus fractures. J Craniofac Surg 2010;21(6):1670-1673.
14. Smith 'fL, Han JK. Loehrl'Il\ et al. Endoscopic management of
the frontal recess in frontal sinus fractures: a shift in the paradigm? Laryngoscope 2002;112(5):784-790.
15. Kim KS, KimES, Hwang JH, et al. Transcutaneous transfrontal
approach through a small peri-eyebrow incision for the reduction ofdosed anterior table frontal sinus fractures. JPlast Reconstr
Aestlut Surg 2010;63(5):763-768.
16. Chu EA. Quinones-Hinojosa A. Boahene KD. lhms-blepharoplasty
orbitofrontal craniotomy for repair of lateral and posterior frontal sinus cerebrospinal fluid leak. Otolaryngol Head Neck Surg
2010;142( 6) :906-908.
17. Strong EB, Buchalter GM, Moulthrop TH . Endoscopic repair of
isolated anterior table frontal sinus fractures. Arch Facial Plast
Surg 2003;5(6):514-521.
18. Kim KK, Mueller R. Huang F. et al. Endoscopic repair of anterior
table: frontal sinus fractures with a Medpor implant. Otolaryngol
Head Neck Surg 2007;136(4):568-572.
19. Graham HD III, Spring P. Endoscopic repair of frontal sinus
fracture: case report. J Craniomaxillofac 'ITauma 1996 Winter;2(4):
52-55.
20. Strong EB, Kellman RM. Endoscopic repair of anterior tablefrontal sinus fractures. Facial Plast Su~g Qin North Am 2006;14(1):
25-29.
21. Lappen l'W, Lee JW. 'Ii'eatment of an isolated outer table frontal sinus fracture using endoscopic reduction and fixation. Plast
Reconstr Surg 1998;102(5):1642-1645.
22. Donald PJ. Frontal sinus ablation by cranialization. Report of 21
cases. An;h Otolaryngol1982;108(3):142-146.
23. De Cordier BC, de la Torre JI, Al-Hakeern MS, et al. Endoscopic
forehead lift review of technique. cases, and complications. Plast
Reconstr Surg 2002;110(6):1558-1568; discussion 1569-1570.

Peter C. Revenaugh

The last 25 years have seen dramatic changes in the

diagnosis and treatment of facial fractures driven by
advances in imaging and the advent of internal rigid fixation. Rapid acquisition of high-resolution images with
three-dimensional (3-D) reconstruction techniques has
facilitated more accurate definition of fracture patterns
and precise preoperative treatment planning. Advances
in biocompatible materials with high tensile strength,
low profile, and absorbable characteristics have allowed
rigid fixation of complex injuries with minimal morbidity. These refinements in technology, along with increased
understanding of facial biomechanics and growth patterns,
have rendered complex injuries consistently amenable to
precise 3-D reconstruction. However, controversy still exists
regarding the suitability of rigid fixation for the developing
pediatric craniofacial skeleton.
Despite controversies, the fundamental principles of
pediatric traumatology are similar to those in adults. Goals
include stable restoration of preinjury architecture with
minimal functional and aesthetic impairment. A unique
challenge to pediatrics is the need to reconcile acute injury
and functional limitations with the potential long-term
growth consequences. Fortunately, there is an increasing
wealth of literature in this arena and this knowledge can
be used to formulate a reasonable treatment plan. The
evaluation and treatment of pediatric facial trauma should
include consideration for the differential injury mechanisms and patterns as well as the potential growth implications on the developing facial skeleton.

EPIDEMIOLOGY
Trauma is the leading cause of death and major contributor to long-term morbidity among children in the United
States (1). There are approximately 15,000 deaths annually from trauma and 100,000 children are permanently
disabled (2). The estimated national health care cost for

1272

Paul Kralwvitz

the treatment of pediatric injuries is over $15 billion (2).

Despite the high prevalence of pediatric trauma, facial fractures in this age group are relatively rare. accounting for
5% to 14% of all facial fractures (1,3,4). This percentage
has remained stable despite advances in motor vehicle and
sport safety and accounts for a significant health care cost
at an average charge of $22,510 for pediatric patients hospitalized with facial fractures (4).
An age differential is generally noted, where patients
younger than 5 years of age are less likely to sustain facial
fractures. Younger male patients are disparately affected at
a rate of 1.5 to 3.1:1 versus females (1,4,5).
Nasal bone fractures likely account for the most frequently
fractured fadal bone. but precise statistics are not available
as the majority of nasal fractures occur in isolation and are
treated in the outpatient setting. More routinely, large studies report fracture incidence based upon emergency department and hospital admissions. Mandible fractures comprise
the majority of these fractures accounting for 20% to 50% of
facial fractures in the pediatric age group (5,6). The condyle
is the most vulnerable and hence. most commonly involved
site in 40% to 70% of mandible fractures (1,6). Rarely seen
in young children, fractures of other mandible sites increase
as children approach adolescence, reflecting adult frequency
and anatomic location. Dentoalveolar trauma and fractures
occur often in children but due to the same limitations in
data gathering, frequency may be higher than reported.
Midfacial fractures are less common in children, but orbital
fractures are the next most frequent midfacial fracture after
nasal bone fractures accounting for 15% to 39% or pediatric
facial fractures (1,5,7). Isolated zygomaticomaxillary fractures occur in 10% to 20% of patients (1,5). Even less commonly. complex midface fractures account for 5% to 10%
of pediatric facial fractures. Panfadal and Lefort fracture
patterns are rarer still and the scarcity and diverse fracture
patterns highlight the challenge in gaining experience in the
treatment of such injuries.

Chapter 85: Pediatric Facial Fractures

Pediatric maxillofacial trauma frequently involves associated injuries due to mechanism and force variability. An
estimated 30% to 75% of children with facial fractures have
additional injuries (3,8). Frequently, pediatric patients
hospitalized with facial fractures have concomitant brain
injuries (32.3%), skull base fractures (27.7%), cranial
vault fractures (13% to 30%), ocular injuries (7.2%), and
cervical injuries (3.3%) (1,3). Orthopedic, thoracic,. and
abdominal injuries are also encountered, reinforcing the
need for comprehensive initial assessment of pediatric
trauma patients. Further, it may be necessary to delay fracture management in lieu of neurologic stabilization. This
delay can complicate future treatment in the rapidly healing pediatric facial skeleton.

EMERGENCY MANAGEMENT
AND PHYSICAL EXAMINATION
Initial assessment of all patients who have experienced
trauma should adhere closely to advanced trauma lifesupport protocols (Table 85.1). Airway management can
be approached using a variety of methods based upon the
patient's injury profile and mental status. For the majority of isolated maxillofacial injuries, adequate positioning
of the patient is sufficient for airway management. given
appropriate consideration for cervical injuries. In addition
to positioning, oral suctioning to remove saliva, blood,
and tooth fragments can be beneficial. In some severe cases
of bilateral mandibular fracture with tongue retrodisplacement, manual traction or midline tongue traction suture
can help maintain airway patency until definitive airway
management.
Orotracheal intubation may be necessary in situations where positioning is inadequate to maintain the
airway, there is neurologic impairment, significant oral
bleeding, or complicated maxillary fractures. Again, cervical spinal injures should be considered and airway
management would ideally follow proper stabilization
of the spine.
If oropharyngeal or laryngeal injuries are present, intubation should be approached in the operating room with
rigid instrumentation available. Emergent cricothyroidotomies or tracheotomies are avoided in favor of orotracheal
intubation. However, elective tracheotomy may be beneficial in patients with panfacial fractures or when fractures
are accompanied by severe neurologic injuries.

EMERGENCIES

~.!.; PEDIATRIC FACIAL TRAUMA

Adherence to the Airway, Breathing, Circulation (ABCs)

Emergent tracheotomies and cricothyroidotomies are ideally
avoided
Septal hematoma requires urgent drainage

1273

DIAGNOSIS AND EVALUATION

Injuries inconsistent with the history should raise suspicion of child
abuse
Secondary survey proceeds in an orderly fashion; neurologic
assessment, manual palpation, inspection of the neck, spine,
eyes, nose, face, and oral cavity
Periorbital edema and hypoesthesia, ecchymoses, subconjunctival
hemorrhage, diplopia, and mobility reduction are indicative of
orbital injury
Suspected orbital trauma warrants an ophthalmologic evaluation
Trapdoor or Hwhite-eyedH fracture can be subtle with limited
supraduction mobility
Malocclusion is indicative of mandibular fracture
Intranasal examination is essential for septal injury, particularly
septal hematoma
CT has revolutionized the evaluation of pediatric trauma

Once the patient has been stabilized according to

trauma protocols, the secondary survey should proceed in
an orderly fashion, keeping in mind that portions of the
exam may be difficult to accomplish in an uncooperative
or neurologically injured child (Table 85.2).
Full neurologic evaluation should be pursued, followed
by examination of the neck and cervical spine. Attention to
overall level of consciousness and cranial nerve integrity is
crucial in this assessment Particular attention to sensation
of all divisions of the cranial nerve V and the motor function of the facial nerve are paramount. Ophthalmologic
examination should focus on overall visual integrity,
pupillary evaluation, range of motion examination,
ophthalmoscopy, or presence of diplopia or ophthalmoplegia. Forced duction testing may be performed, usually
under anesthesia in cases of suspected orbital trauma.
Otoscopy may reveal hemotympanum or cerebrospinal
fluid (CSF) otorrhea associated with temporal bone fractures. External auditory canal lacerations associated with
mandibular condylar fractures or displacement may also
be seen on otoscopy. Anterior rhinoscopy should focus on
ruling out nasoseptal injuries, particularly hematomas and
CSF rhinorrhea. Full oral examination is crucial to assess
occlusion, dentoalveolar injuries, missing or broken teeth,
tongue injuries, or palatal fractures associated with midface injuries.
The facial skeleton should be approached in a systematic fashion with observation followed by palpation.
Facial asymmetry, ecchymosis including '"raccoon eyes
or Battle sign, edema, periorbital edema, conjunctival
chemosis, epistaxis, malocclusion, trismus, and gingival
laceration all are signs of potential underlying fractures.
Once the face has been thoroughly inspected, palpation
of the buttresses follows, usually beginning at the zygomatic arches or supraorbital rims and proceeding caudally.
Asymmetry, tenderness, mobility, or crepitus should be

1274

Section V: Trauma

noted wherever present. Areas of frequent fracture should

be examined including the nasal bones, orbital rims,
and malar eminences. Assessment of midface stability is
accomplished with attempted movement of the premaxilla
with one hand while stabilizing the head with the other
hand. Maxillary buttressing can also be palpated intraorally. Bimanual palpation of the mandible should focus
on loose teeth or tooth segments, and attempted elicitation of mobility in multiple vectors. Any missing teeth
should be catalogued and considered as a potential source
of airway foreign body. As with the facial skin. oral mucosa
and all oral structures should also be inspected.
As time and witness availability allows, an accurate history should be obtained. Injury mechanism and assessment of velocity may predict potential fracture patterns or
concomitant injuries. Any suspicious stories or inconsistent injuries should raise the threshold of concern for child
abuse or nonaccidental injury.

RADIOGRAPHIC EXAMINATION
Computed tomography (CI) has revolutionized the diagnosis and treatment of facial fractures. Contemporary scanners allow rapid image gathering. ultrafine cuts ( 1 mm ),
multiplanar and even 3-D reconstructions for fracture
identification and treatment planning, especially in the
multiply injured children. Axial cuts provide a reasonable
starting point for overall facial assessment and are particularly useful in the mandible, midface, nasal bones, and
frontal sinuses. Coronal cuts are necessary for evaluating
the orbital floor and may provide valuable information
regarding the mandibular condyle. Sagittal cuts can provide additional information about the orbital floo~; roof,
and overall facial and mandibular projection.
Though cr is regarded as the gold standard for facial
skeletal assessment, mandible panoramic x-rays (Panorex)
are still useful in the evaluation of the isolated mandible
fracture. Care should be taken to ensure condyle inclusion
and the clinician should understand that Panorex: may be
inferior to helical cr in evaluation of the condyle or multiply fractured mandible (9). Plain films are now of little
use in facial fracture workup and may delay diagnosis or
miss facial fractures (5, 10). Howeve~; nasal plain films are
still commonly encountered in the emergency department
setting. One should recognize the potential inadequacy of
facial plain films and the subsequent need for cr in cases
of nasal fracture where there is significant deformity and
flattening of the dorsum or a history of significant contributing force. Howeve~; imaging in the vast majority of isolated pediatric nasal injuries is unnecessary.
H

ETIOLOGY/MECHANISM OF INJURY
The variable structural characteristics of the developing
face and skull in relation to the mechanism of trauma
determines the risk and pattern of facial fractures. Young

children are generally spared from facial fractures due in

part to their protected environment and minimal engagement in activities known to be risk factors for fractures.
When considering all types of pediatric facial fractures,
including nasal and dentoalveolar, childhood play may
account for the greatest percentage (11). Howeve~; motor
vehicle collisions account for the vast majority of serious
facial fractures (1,5). The risk of serious facial fracture is
doubled by inappropriate motor vehicle restraint in children (1, 12). Falls, interpersonal violence, and sporting
injuries are all common causes of fractures and vary in percentage based upon the age group of the patient. Bicycles
have remained a common cause of pediatric facial fractures. Though helmets have contributed to a reduction in
intracranial injuries and midfacial injuries, they do not
protect against mandibular and dentoalveolar trauma ( 13).
Fractures in young, especially preambulatory patients, or
fractures of the mandible should be remembered as a possible indication of child abuse (3).
The anatomic development of the face is important to
understand the different patterns of fracture seen between
adults and children. At birth, the ratio of cranial to facial
volume is approximately 8:1 with the face set in a recessed
position. The relative protection of the skull contributes to
a lower incidence of facial fractures, but a higher incidence
of skull fracture and intracranial injury in young children
(14). Facial growth generally occurs in a downward and
forward direction and begins to outpace cranial growth
after the second year of age. The orbit and brain near completion of growth by age 7, but facial growth continues
well into the second decade of life. In the developing face,
the bones have less mineralization with a greater proportion of cancellous bone, thinner cortices, and the sutures
are not fused in infants. These factors, combined with the
presence of multiple tooth buds and the lack of paranasal
sinus development, make the infant craniofacial complex
a solid yet elastic structure, resisting fracture. These factors
also contribute to the higher proportion of greenstick fractures observed in pediatric patients. Likewise, suture ossification, sinus pneumatization, tooth eruption, and greater
independence contribute to the transition from pediatric
to adult fracture patterns.

FACIAL GROWTH AND TRAUMA

Understanding of craniofacial growth and its relation to
trauma is limited. Coordination mechanisms of facial
growth and the exact genetic and environmental contributions are unclear. A complete discussion of the various theories of facial growth and regulation is beyond the scope of
this chapter. However, it is fairly accepted that facial skeletal growth and development consists of remodeling and
displacement combined with inner table resorption and
outer table deposition (15). Factors contributing to bony
growth undoubtedly include finely regulated local and systemic factors as well as vector forces acting on the bones.

Chapter 85: Pediatric Facial Fractures

1275

B
Figure 85.1 A; 3-D CT 1"8ClDnstruc:tion of a 3-year-old child with mandibular hypoplasia, retrognathism, and right temporomandibular ankylosis. The dlild had a history of Cl\ISh injury to the right
mandibular condyle in the first year of life. B: 3-D CT 9Can of Ute child depicted in {A) shows a normal
left condyle and an abnormal, hyperplastic right condyle with a foreshortened condylar neck ankylosed in the right temporomandibular joint.

The facial skeleton can be divided into two independent,.

yet related growth areas-the nasomaxillar:y complex
and the mandible. Alterations in growth and remodeling
within and between these areas due to trauma contribute
to the deformities and dysfunction observed.
Mandible growth has long been associated with the condyle, although it is likely there are a series of growth centers
that contribute to overall growth. .& an area of continued
growth throughout childhood the condyle seems to have
an ability to remodel quickly (less than 12 months) under
the strains of mastication ( 16,17). Howevex;. CJ'Wih injuries
to the condyle and injuries involving condylar head can
lead to mandibular and maxillary growth asymmetries
or ankylosis (Fig. 85.1) (18). Norh.olt et al. (19) demonstrated that younger children have fewer deformities following trauma suggesting that growth may compensate for
the injury. Contrary, Rowe (2) found that injuries occurring
before 3 yeaa of age generally produced more severe deformities. Despite these apparent disparities, there is consensus that early return of mandibular mobility in pediatric
patients is desirable to limit the risk of ankylosis and to
stimulate normal growth and remodeling.
The nasomaxillaxy complex appears more sensitive to the
effects of trauma on normal growth. This may be due to the
multiple suture sites, limited functional restorative mOYmient
compared to the mandible, or the importance of the septum
as a regional growth site. Numerous animal swdi.es involving
septectomies and septoplasties in the last three decades have
continued the debate into the role of the septum as a growth
center for the midface (20-22). Small case series and twin
swdi.es in humans have demonstrated midfacial hypoplasia

following trauma to this area (23). Surgical manipulation

of the nasoseptal area in the pediatric population auries the
same concerns for midfacial or nasal growth alte:Jation; how~ evidenre is limited (24). Unless functional limitation or
gross deformity e:x:ists, minimal SUJgial manipulation of the
area is recommended, especially in the area where the septal
cartilage contacts the bony sepWm. ( 25).
The potential effects of trauma on growth should be a
counseling point with parents following injwy and care
should be taken wherever possible to minimize additional
growth alteration risk during treatment. Minimizing additional risk would include careful restoration of the periosteum and other soft tissues with minimal periosteal
elevation. attention to realignment of the septal cartilage
where possible, and accurate reduction with correct suture
realignment. Long-term follow-up for pediatric trauma
patients is essential in identifying alterations in growth and
initiating appropriate orthodontic treatment if necessary.

RIGID FIXATION
The role and best use of rigid fixation in children is still
controversial, given the aforementioned concerns regarding facial growth and other potential complications of
internal fixation (Thble 85.3).
As with traumatic injuries, animal studies have investigated the potential growth retardation related to plating.
Plating across suwre lines and elevation of the periosteum has demonstrated restricted growth in several animal
models (26,27). Laurenzo et al. (27) observed an equivocal amount of growth restriction between rabbits that had

1276

Section V: Trauma

'Ill

COMPUCATIONS

..... FACIAL FRACTURES

The nose, nasoethmoidal complex, and maxilla are susceptible to
growth abnormalities as a result of trauma
More severe types of pediatric facial trauma are associated with
concomitant injuries- especially neurologic in up to 60% of
patients
Fracture complications can include delayed sinus infections,
malunion, malocclusion, TMJ dysfunction, and delayed growth
disturbances
Inadequate treatment of upper and midfacial injuries may result in
serious alterations of facial growth
Bone growth can cause translocation of metallic implants

trauma and those that had trauma and subsequent fixation.

They concluded that plating offers no additional growth
restriction beyond that of the initial trauma. Their group
then reported that subsequent removal of the plates had
additional detrimental effects to growth in rabbits (26).
Human studies have also demonstrated growth restriction in the setting of plated fractures (28). These data
have caused some clinicians to recommend plate removal,
although detractors would cite the animal evidence that
removal may further traumatize growth centers and less
than 8% of patients who are observed eventually require
plate removal (28). Independent of growth considerations, metallic hardware can be complicated by palpability, hypersensitivity. bone atrophy. tooth bud injury, and
potential interference with future imaging. Plate displacement, plate and screw migration (even intracranial), and
plate isolation are also complications to consider when
planning rigid fixation (29).
To avoid the complications associated with permanent
plates and screws in the developing face, absorbable plating systems have been developed. The safety and efficacy
of these systems have been established and this technology
gained U.S. Food and Drug Administration (FDA) approval
in 1996. High molecular weight polyalphahydroxy adds are
the most commonly used craniofacial bioabsorbable materials including polylactic add (PLA) (both Lando enantiomers ), polyglycolic add (PGA), polydioxanone (PDS), and
their copolymers. Biodegradation of PLA and PGA occurs in
two phases; a hydrolysis phase where water molerules cleave
the larger macromolecules, and a metabolic phase where
macrophages phagocytize the polymer fragments (30).
Substantial strength loss ocrurs during the hydrolysis phase
and the space occupied by the absorbable screws is eventually obliterated by bony ingrowth (30). During degradation, PLA and PGA are metabolized into carbon dioxide and
water and eliminated through respiration whereas PDS degradation products are primarily excreted in the urine (30).
Pure polymers have disadvantageous properties in regard to
strength, degradation time, and local tissue reactions.
Currently available plating systems utilize copolymers
of PLA and PGA allowing a variety of strength profiles and

degradation times from 6 months up to 6 years (30). Physical

and biomechanical studies have demonstrated that available
absorbable plates provide flexural and tensile strength comparable to available titanium microplate systems ( 31 ). Ideally.
plate resorption should occur after the 4 to 6 weeks necessary
for full fracture healing and indeed, commercially available
systems retain 60% to 80% of their strength at 10 weeks (30).
Complications observed with absorbable plating commonly include peri-implant edema, temporary visibility,
and palpable hardware (30). Degradation appears to elicit
only a mild foreign body reaction in the surrounding tissue. As in permanent fixation, some controversy exists
regarding the potential growth restrictive properties of
absorbable plating procedures. To date there have been few
long-term studies to address this possibility.
Currently, resorbable plating systems are recommended
for "non-load-bearing" areas of the upper face and midface. Although plating of mandible fractures and saggital
split osteotomies have been described, their use in these
contexts is still investigational in children with limited
long-term data (32). The somewhat larger screws, thicker
plates, and limited malleability of absorbable systems can
limit use in areas of thinner skin or in severely comminuted fractures. As technology improves, changes in product properties and indications are expected.
While it has been demonstrated that open reduction
and internal fixation (ORIF) for the treatment of mandibular and complex midface fractures is safe and efficacious,
especially in children older than 13 years, the risks and
benefits of internal fixation must be weighed prior to intervention (Table 85.4) (3).
Many minimally displaced or greenstick fractures can be
managed conservatively. Management of moderately displaced fractures requires higher clinical arumen and can
be guided by postreduction stability. However, in certain
complex cases, or load bearing segments, rigid fixation cannot be avoided. Whether rigid or absorbable, plates should
be as small as possible without compromising stability. as

11J11 TREATMENT

~, PEDIATRIC FACIAL FRACTURES

Orotracheal intubation is ideally accomplished after securing the

cervical spine
Careful restoration and resuspension of injured soft tissue
Reduction of fractures into stable anatomic locations
ORIF is indicated in unstable fractures
Correct realignment of suture lines
Minimal periosteal elevation
3-D, stable fixation
Use of bone grafts in areas of bone loss
Mandibular fractures with normal occlusion and mobility treated
with soft diet
Malocclusion or movement limitation treated with MMF or ORIF
Traumatic telecanthus associated with nasoorbitoethmoid fractures is best treated with transnasal wiring

Chapter 85: Pediatric Facial Fractures

short as possible, and ideally not placed over more than
one suture. Periosteal elevation should be minimized and
dissected tissues reapproximated precisely.

SURGICAL APPROACHES
Despite advances in rigid fixation, it is important to
remember that many pediatric fractures can be managed
with closed techniques. In cases of displaced or complex
fractures where fixation may be necessary, much of the
facial skeleton can be exposed through a single incision or
combination of several incisions.
The upper third of the face can be approached through
a coronal incision to access the upper orbital rims, forehead, and nasoorbitoethmoid (NOE) complex. Subfascial
release of the temporalis fascia allows complete exposure
of the zygomatic arches. Exposure of the orbital rims can
be accomplished using a subciliary or more popularly a
transconjunctival incision with or without a lateral canthotomy. The medial orbit and apex can be approached
via a transcaruncular incision (33). For important realignment of the midfacial nasomaxillary and zygomaticomaxillary buttresses, an upper gingivolabial sulcus incision
can provide access to the entire maxilla and zygoma with
care taken to identify the infraorbital nerve. In the case of
especially complicated fractures requiring wide exposure, a
midfacial degloving approach can be used.
Fractures of the mandibular symphysis, body, and angle
can be approached through a lower gingivolabial sulcus
incision. Rarely, plating of ramus fractures or comminuted
fractures of the angle and body can be reduced through an
external approach.
As always, tenets of limited periosteal dissection with
careful restoration of soft tissue should be observed. In
complex fractures, accurate reestablishment of facial buttresses to provide preinjury occlusion, facial width, and
height is fundamental.

NASAL FRACTURES
Visual examination of the pediatric nose reveals the differences in anatomy from the adult nose. Children have limited nasal projection and the projecting tissue comprises
soft cartilage that is compliant to physical forces. As a result,
the pediatric nose deforms readily, dissipating force across
the maxillary soft tissues and lateral buttresses. Rarely are
the nasal cartilages injured. However, the underlying septum is relatively rigid and prone to injury with trauma of
significant force. Three types of septal injuries are observed
in children. The perichondrium can be sheared from the
septum creating a potential space for blood and resultant
hematoma. Secondly, a dislocation of the caudal septum
can lead to nasal deformity and obstruction. Lastly, separation of the bony and cartilagenous septum can be observed,
leading to nasal obstruction and growth abnormalities.
Nasal bones have limited projection in young children and therefore are rarely fractured in this age group.

1277

Fracture risk increases with age and if present in younger

children, they can be of the greenstick variety. In addition
to limited projection, the nasal bones are not fused in
the midline in young children, resulting in "open-book
fractures where the nasal bones are separated in the midline and splayed over the maxilla. Clinicians should have
an index of suspicion for occult nasoorbitoethmoid fractures in children with fractures of the nose with "openbook" fractures or a history of direct trauma to the nasal
bridge.
Initial examination is often of limited utility due to the
presence of midface edema from force dissipation and the
lack of external deformity. Several days of observation may
be necessary before the true cosmetic deformity can be
appreciated. Initial examination must focus on evaluation
for septal injury and hematoma. Nasal obstruction and
unilateral septal bulging are hallmarks of a hematoma.
A septal hematoma will classically appear purplish and
compress with manipulation but not resolve with decongestion. Untreated and even treated hematomas can lead
to a variety of complications including a fibrotic septum or
loss of cartilage and resultant saddle-nose deformity (34 ).
Treatment of a septal hematoma is best approached
under anesthesia in the pediatric population. The hematoma is incised via a Killian incision, allowing exploration
of the septum and limited reduction of cartilaginous fragments. Through-and-through quilting suture should reapproximate the mucoperichondrial flaps. Septal splints can
be used for 2 to 3 days to prevent reaccumulation. Packing
can be poorly tolerated and only advised if there is strong
justification for its use. Perioperative antibiotics are recommended. Closed reduction can be accomplished in the
same setting if dorsal nasal fractures are encountered.
If no hematoma is encountered and there is no notable nasal deformity, the patient can be reevaluated in
3 to 5 days once edema has resolved enough to reveal any
deformity. If bony or septal injuries are discovered causing a fixed nasal obstruction or poor cosmesis, definitive
management is recommended. Usually, dosed reduction
is sufficient. Greenstick fractures and septal fractures may
require open approaches to adequately reduce. Injuries
presenting 2 to 3 weeks postinjury may require open reduction due to rapid ossification. Timing of open reduction is
debated and should take into account the deficit or defect,
patient age, and potential for altered growth.

NEWBORN NASAL DEFORMITY

Occasionally newborns may be born with a grossly asymmetric nasal tip. Intrauterine positioning and trauma while
traversing the birth canal are two potential etiologies.
Classically, the septum is deviated to the same side of the
nasal tip and the nasal dorsum is unaffected. Since neonates are obligate nasal breathers, nasal obstruction would
be an indication for early septal relocation. Otherwise, the
nasal tip and septum eventually straighten in the majority
of cases and reassurance is all that is needed (35).

1278

Section V: Trauma

FRACTURES OF THE MANDIBLE

Fmctures of the mandible account for 13% to 48.8% ofpediatric facial fractures with increasing frequency u patients age
(1,5, 7). Concerns aver the developing face and dentition
dictate management decisions, which are somewhat different in pediatric versus adult patients. Although. treatment
modalities may differ, the avaall goal is accumte alignment
and reduction with restoration of preinjwy occlusion.
Unique to the pediatric mandible are concerns presented by the developing dentition. Until age 2 there is
incomplete eruption of the deciduous teeth. In thia age
group traditional methods ofimmobilization may be inadequate. Age 2 to 5 ye;us, the deciduous incisors and molars
have firm roots for fixation if needed. From age 5 to 9 there
is mixed resorption of the deciduous roots and incomplete

eruption of the secondary dentition. Once children are

10 to 12 years old, an adequate compliment of secondary
teeth for fixation is present.
Maxillomandibular fualtion (MMF) is used more sparingly in the pediatric population given concerns for joint
ankylosis, tooth development. and general airway concerns.
If deemed nea!Silary, 2 to 3 weeb of immobilization in children less than 12 years ofage is adequate. When used. differences in dentition phase may dictate MMF type. Patients who
have no teeth or limited deciduous teeth. an acrylic splint
can be fabricated using plaster casts of the upper and lower
dentition positioned in estimated occlusion to cast the final
splint.lhe acrylic splint can be seaued using circum-mandibular and transnual wires (Fig. 85.2). Alternativdy, screws
can be placed in the zygoma and inferior mandibular border and serured with monofilament suture. However, this is

D
Figure 85.2 A:. Towne view shows right parasymphyseal mandibular fracture In 8 3-yea!'oOid girl.
B: Clinical photograph shows 1he fract:ure depleted In (,\). C: Acrylic splint fabricated on 8 plastic
cast of 1he mandible. The original Impression of the mandibular arch was cut and the occlusion
established to the maxillary Impression before fabrication of the splint. D: Acrylic splint wired Into
place with drcummandlbular wires.

Chapter 85: Pediatric Facial Fractures

1279

B
Figure 85.3 Coronal (A) and 3-0 n~constructlon (B) CT Images of a 10.month-old Infant with
bilateral dlsplaa~d subcondylar fractures. Coronal view shows symphyseal greenstick fracture of the
lingual cortex. This child was treated expectantly.

inadvi8able in older patients as the masticatory musdea may

be strong enough to resist the fixation. Once patients are 2
to 5 years old, the deciduous teeth have firm enough roots
for cap splints and ardl bars. Aidl bars may be difficult to
semre, howem;. due to the shape of the teeth. Ifusing MMF
from age 2 to 5, augmentation of :fixation may be obtained
using pyriform aperture and cirolm-mandibular wiring.
After 10 years of age, children generally have enough permanent dentition to serurely place arch bars.
Consideration for the growing face cannot be overemphasized in fracture management. Complicatiom of
pediatric mandibular fractures in general can include malocclusion, malunion, nonunion. infection. tooth loss, and
temporomandibular joint (TMJ) dysfunction. Greenstick
fractures are common and teeth are often encountered in
the fracture line and should not be removed unless devitalized (36). Prolonged MMF places the patients at risk for
TMJ ankylosis, which can be difficult to treat and ret~ult in
growth abnormalities.

FRACTURES OF THE CONDYLE

Fractures of the condyle account for the majority of mandibular fractures in children (6). These can be classified
into three anatomic types: intracapsular CJ'Wih fracture of
the condylar head, high condylar fracture above the sigmoid notch, and low subcondylar fracwre. The low subcondylar fracture is the most common type with many
being greenstick fract.ures. Although the condylar head has
rapid resorption capabilities, there is evidence to suggest
that trauma to this growing area can result in growth arret~t
or functional or radiologic deformity in up to 20% of
patients (37). Therefore, long-term follow-up and possible
orthodontic intervention is advised.

Most clinical and experimental data suppon a conservative dosed approach to the majority of condylar fractures. A primary clinical decision point is usually whether
or not to immobilize the patient. Often, unilateral condylar fractures with normal range of motion and normal
occlusion. a soft diet and movement exercises are all that
is necessary. If there is good occlusion, but deviation with
movement. arch bars with elastic guiding bands may be
helpful. Commonly, an open bite may be a sign of unilateral or bilateral condylar fracture (Fig. 85.3). If there is
an open bite, mandibular retrusion, or movement limitation, a shon course (2 to 3 weeks) of MMF may be helpful followed by elastic bands if needed. Open surgical
repair of the condyle is rarely indicated except in instances
of displacement into the middle cranial fossa or severely
restricted mandibular movement Preauricular and submandibular approaches can be used.

FRACTURES OF THE ARCH OF THE

MANDIBLE
Fractures of the arch of the mandible can range from
greenstick fractures to displaced bicortical fractures and
are commonly associated with fractures of other mandibular site in up to 30% of cases. Often, masticatory muscles
exJ:rt unfavorable forces on fractures of the anterior arch
causing displacement that can be carefully reduced under
anesthesia.
'Ii'eatment of arch fractures ranges from soft diet to
MMF or ORIF with miniplate :fixation. Arch bar placement can be complicated by dentition stage and unfavorable splaying of the inferior border of the fracture. If rigid
fixation is used, monocortical screws should be placed
with cognizance of the underlying developing tooth buds

1280

Section V: Trauma

are signs of an underlying fracture.

cr with multiplanar

views is essential in diagnosis and treatment of midface

Figure 85.4 Proximity of the uncmJpted canine and bicuspid

teeth to the lower margin of the mandible.

(F'tg. 85.4). Howner, once children have a full complement of secondary dentition. adult treatment algorithms
apply. Currently, absorbable plating systems are not FDA
approved for mandible fracture treatment {30). Fractures
of the body and angle commonly are of the greenstick variety, typically with normal jaw movement and occlusion.
In these cases, soft diet and observation is appropriate.
Conservative plate placement again should be observed if
internal :fixation is deemed necessary.

DENTOALVEOLAR FRACTURES
Dentoalveolar fractures are relatively common in pediatrics
involving the indscm and canine teeth most often (38).
Treatment of these fractures should occur on an emexgent
basis to stabilize the traumatized bone and teeth. Avulsion
of primary teeth without bone is not serious, but it is often
diffiadt to determine if a tooth is primary or secondary; so
reimplantation of any avulsed teeth is a safe strategy. Acute
treatment involves preserving and cleaning of the tooth
with replacement in the socket in cooperative patients
while arranging prompt dental consultation. If the child is
uncooperative, the tooth can be placed in a saline solution.
moist gauze, or submersed in milk until dental implantation. Every effort to implant within 1 hour of injwy should
be made to give the best chance for recovery. Theatment of
the loss of multiple teeth or alveolar bone is challenging
and may require MMF or miniplate fixation, generally with
poor tooth survival rates (38).

FRACTURES OF THE MIDFACE

Fractures involving the midface, orbit, and nasoethmoidal
region are rare in children and often result from significant
forces with associated intracranial injuries. Injuries can
range from isolated o:rbital blow-out fractures to severely
comminuted fractures involving multiple facial buttresses.
Severe facial edema, orbital ecchymosis, and malocclusion

fractures. Ophthalmologic examination should be undertaken with any fractures involving the o:rbit. Evaluation
for vision loss, enophthalmos, exophthalmos, globe rupture, vertical dystopia, or elevated intraocular pressure is
necessaxy. Sensoty nerve integrity and intercanthal distance should also be inspected. Medial canthal stability
and forced duction tests are generally reserved for patients
under general anesthesia.
In midface fracture treatment, a multidiscipliruuy
approach is necessaxy with the goal of therapy to establish
facial symmetty, 3-D proportions, occlusion, and function.
Taking into account the overall medical condition of the
patient after a potentially severe trauma, fracture reduction
should be attempted within 10 days. Pediatric bone can
reossify rapidly, making future correction difficult. If necessary, arute reduction can be attempted through existing
lacerations.
Lefort fracture patterns can be used to describe complicated midface fraelllres. Howna;. these classifications are
rarely adequate in pediatric midface fractures due to the
variety of fracture patterns associated with variable paranasal sinus development With high-velocity midface injuries, fractures of the palate instead of Lefort I pattems can
be obsem!d due to lack of maxillary sinus development
and incomplete midline palatal fusion. Oblique fractures
extending through the frontal bone and fractures of the
cranial vault are also observed with upper midface trauma
(39). Due to the variety of fractures, classification schemes
to describe treatment implications have been proposed ( 11).
Type I fractures are minimally displaced, Type II are moderately displaced with some areas of comminution. Type D
injuries can involve multiple buttresses, but the fragments
are IOO)gnizable and large enough to rigidly fix. Type Ill
fmctures are severely displaced with multiple areas of comminution involving buttresses where 3-D stabilization and
bone grafting may be necessary for adequate reduction.

FRACTURES OF THE
ZVGOMATICOMAXILLARY COMPLEX
Zygomaticomaxillaxy complex fractures generally do not
occur under the age of 5 owing to the lack of maxillary
sinus pneumatization. After this age, fracture patterns
re11emble those in adults although involvement of the
orbital floor and rim can be obse:l'\'led more frequently in
children (40). Greenstick fractures of the frontozygomatic
suture and zygomatic arch with medial displacement of
the malar fragment are commonly seen. In these cases,
single-point fixation of the zygomaticomaxillary buttress
may be adequate. More often, two- or three-point :fixation
is required and proper reduction should be confirmed with
palpation at the zygomaticomaxillary, frontozygomatic,
and even zygomaticosphenoid sutures. Fixation is often
undertaken at the zygomaticomaxillary buttress through a

Chapter 85: Pediatric Facial Fractures

gingivolabial incisio~ and at the orbital rim and/or frontozygomatic suture through a subciliary or transconjunctival incision with lateral canthotomy. If exposure of the
zygoma is necessary for complex or comminuted fractures,
a hemicoronal incision can be added.
Isolated zygomatic arch fractures without displacement
can be observed with institution of a soft diet. Minimally
displaced fractures can be reduced via the intraoral route,
a Gillie approach or even directly through existing wound
or transcutaneously with a bone hook. Contingent upon
reduction and stability, isolated zygomatic fractures may
not require further fixation.

FRACTURES OF THE ORBIT, ORBITAL

ROOF, AND FRONTAL BONE
Fractures involving the orbital and orbitoethmoid area can
range from simple to quite complex and result in severe
functional deficit and poor aesthetic outcomes. Thirty percent of orbital fractures are associated with other facial
fractures (41). As with midface fractures, ophthalmologic
consultation is imperative and consideration for intracranial injuries should be maintained, especially in cases of
orbital roof, frontal bone, NOE, or bilateral orbital fractures. Assessment of visual acuity should be primary as
optic nerve injury can result from apex fracture or extension of orbital wall buckling. Loss of visual acuity and the
presence of an afferent pupil defect are hallmarks of optic
neuropathy. Fractures of the orbital apex are exceedingly
rare and usually associated with other nonsurvivable injuries due to the force required to injure this area. Attention
should also be given to orbit position, extraocular movements, pupillary abnormalities, cranial nerve V integrity,
and intercanthal distance.
Fracture patterns in this area tend to be age specific
paralleling paranasal sinus development. Maxillary sinus
pneumatization generally begins after age 5, when isolated
orbital floor fractures are more often seen. The ethmoid air
cells continually expand throughout childhood, reaching
70% of interorbital width by age 7 and frontal sinus development generally begins around age 6 ( 42).

ORBITAL FLOOR AND MEDIAL WALL

FRACTURES
Due to lack of sinus pneumatization, isolated orbital floor
fractures are infrequent in young children. In older children, they are more commonly seen as a result of play or
sporting injuries. Coronal CT offers the best depiction of
these fractures and ophthalmologic evaluation should be
included in the work-up, but serious ocular injury occurs
in less than 5% of isolated orbital blow-out fracture (43).
Diplopia, enophthalmos, periorbital edema, echymosis,
and infraorbital hypesthesia can be observed. Fracture
patterns have been described as trapdoor or ..saucer"
patterns.

1281

The trapdoor fracture is a linear orbital floor fracture,

hinged medially that can allow herniation of orbital contents into the maxillary sinus (43). These are more commonly seen in the pediatric populatio~ probably due to
a higher incidence of greenstick fractures, where selfreduction occurs. Trapdoor fractures are also known as
white-eyed" fractures due to their subtle presentation.
Extraocular mobility reduction with forced duction examination is diagnostic (44). cr may reveal linear fracture
along infraorbital nerve but is not necessary for diagnosis.
Urgent surgical intervention is indicated in cases of entrapment with oculocardiac reflex resulting in emesis, bradycardia, and/or arrhythmia (45). True entrapped fractures
should be explored within 48 hours to reduce risk of permanent diplopia or symptomatic oculocardiac reflex (46).
Saucer fractures result in a depressed orbital floor with
potential for herniation or orbital contents and resultant
enophthalmos. Surgical intervention in nonurgent cases is
based upon need for concomitant exploration with other
fractures, significant enopthalmos (greater than 2 mm),
extraocular muscle restriction on forced duction, symptomatic diplopia, or cr findings indicating large fracture
(greater than 50% of the orbital floor or wall) ( 4 7). Patients
not indicated for surgery can be observed for a period of
days to weeks for resolution of edema or diplopia. The
orbital floor can easily be exposed through transconjunctival or subciliary incision with delicate reduction of bone
fragments. An array of repair materials has been cited
throughout the literature. The more commonly described
absorbable gelatin film can be used for reconstruction of
floor defects and if necessary split calvarial bone for larger
defects.
Medial orbital wall fractures rarely occur in isolation
and are commonly denoted by orbital emphysema on cr
scan (33). Surgical repair is indicated for fixed enopthalmos or entrapment of medial muscles. Exposure can be
facilitated through transcaruncular or external ethmoid
incision, with a transcaruncular approach offering a more
inconspicuous scar (33).

FRACTURES OF THE NASOETHMOIDAL

COMPLEX
Nasoorbitoethmoid fractures involve the central core of
the face including the nasofrontal suture, nasal bones,
medial, and inferior orbital rim. These fractures can
range from minimal displacement to complicated comminution. cr is essential in operative planning with
axial images demonstrating degree of posterior displacement into the ethmoid sinuses and coronal images
displaying medial wall and orbital floor displacement
(Fig. 85.5). Medial canthal tendon integrity should be
investigated under general anesthesia with a hemostat
inserted intranasally toward the medially orbital rim.
Additionally, intercanthal distance should be measured to determine hypertelorism. Although there is

1282

Section V: Trauma

FiguN 85.5 Coronal CT reconstruction of a complex nasoethmoidal fracture in a 12-year-old child. Disruptions of the nasomiVIillary buttress are evident on Ute right, the medially orbital wulls
bilaterally, and Ute orbital floor on the left.

considerable variability in intercanthal distance between

individuals, the average distance at age 3 is 25, 28 mm
at age 12, and reaching 30 mm in adulthood (48). Five
millimeter of widening is suggestive of a displaced fracture while 10 mm is diagnostic.
Status of the fragments can aid in treatment planning.
Fractures can be categorized into three types based upon
fragment status (49). In type I frac:t:urf!a 1he medial canthal
tendon remains attached to a central fragment of bone,
type II fractures display comminution of the central fragment without extending deep to 1he anterior lacrimal crest.
and type III fractures are severely comminuted.
ORIF is the most reliable method of treatment with
correction of the intercanthal distance paramount
Overcorrection may result in superior results versus undercorrection. Existing lacerations or bicoronal incisions can
be used for intervention. Plating, wiring, and calvarial
bone grafts for domal reconstruction may be necessacy.
Wuing can be accomplished by drilling bilateral holes in
the anterior lacrimal crest just above and posterior to the
anterior insertion of the tendon and in the posterior lacrimal crest just behind 1he insertion of the posterior limb
of 1he tendon. TWenty-eight-gauge Kirschner-wire can be
threaded through the holes and tightened to desired correction. Additional plate stabilization may be required and
small screw~ can be used to anchor 1he wires if desired.
Complications can include poor aesthetic outcome or
rarely lacrimal system injw:y.

ophthalmologic consultation is required. While 1he Oibit

and the globe rarely suffer significant long-term damage,
concurrent intracranial injuries occur in upwards of 86%
of oibital roof fractures (3,50). This is especially true in
older children where more significant force is required to
fracture the orbital roof. Treatment of such injuries should
be handled in a multidisciplinacy fashion with neurologic
injuries at the forefront
A classification scheme based upon orientation of
the fractured segments has been proposed (50). Type
I fractures have comminution of the orbital roof without displacement. type 11 have displacement of the fragments toward the anterior cranial fossa whereas type
III fractures have displacement inferiorly into the omit.
Most fractures of the oibital rim do not require operative intervention. Type III fractures have been associated
with permanent exophthalmos, vertical dystopia and
encephalocele and therefore repair via combined intracranial and extraaanial approach with calvarial bone
graft can be considered. A period of observation for 7 to
10 days for any resolution of dystopia or exophthalmos
may be prudent in less severe injuries. However, longterm follow-up with imaging is recommended due to the
appearance of late encephalocele. Hallmarks of orbital
encephalocele are vertical dystopia, axial proptosis, and
globe pulsation.

FRACTURES OF THE FRONTAL SINUS

Development of the frontal sinus occurs late in childhood;
1herefore, fractures are not common until adolescence.
Isolated anterior table fractures can occur from sporting
injuries, but overall, frontal sinus fractures results from
high-impact ttauma and in 70% of cases the posterior table
is involved (51). Deformity of the anterior table must be
addressed through reduction, which can be accomplished
through bicoronal incisions. Careful assessment of the :frontal recess should be accomplished both endoscopically and
directly if possible. Posterior table reconstruction should
be commenced based upon the same criteria as adults and
often with neuroswgical consultation. Long-term followup with periodic imaging is crucial. Complications can
occur bo1h arutely and late, consisting of CSF leak, intracranial abscess, and mucopyelocele formation.

CONCLUSION
FRACTURES OF THE ORBITAL ROOF,
SUPRAORBITAL RIM, AND FRONTAL
BONE
Fracture of the orbital roo ~ and frontal bone are more
common in young children due to 1he large cranium to
face ratio and nonpneumadzed frontal sinuses. 'JYpical
history is of a blow to the brow with a late-developing
hematoma. Other findings such as proptosis or dystopia can occur later and as with other orbital injuries,

Pediatric patients suffer a somewhat different injury profile

1han adults with facial trauma Basic tenets of tmumatic stabilization should be obseiVed followed by more directed
evaluation and treatment Under the age of S pediatric
patients suffer fewer fractures and a higher proportion of
greenstick fractures due in part to 1he elastic nature of the
facial slreleton and the somewhat protected environment
As children age, fracture patterns begin to resemble those of
adults with a higher proportion of mandible and midface

Chapter 85: Pediatric Facial Fractures

fractures. Howevex; partly due to the rapid healing ability

and constant gro~ many fractures can be managed conservatively. When necessary, rigid fixation should consider
potential facial growth abnormalities, but basic principles of
prope~; stable reduction should not be sacrificed. Continued
evolution of absorbable plating systems may help reduce
potentially deleterious effects of permanent rigid fixation.
OveralL the evaluation and treatment of pediatric facial
trauma should include consideration for the differential
injury mechanisms and patterns as well as the potential
growth implications of the developing facial skeleton.

Trauma is the leading cause of death and a major

source of morbidity in children.
Nasal fractures are the most common facial bone
fractured in children. Mandible fractures are the
most common facial fracture among children hospitalized for trauma.
Facial growth and development is closely related to
fracture patterns and the potential for future growth
alteration.
Midface and condylar fractures are associated with
the greatest risk for growth disturbances.
Conservative approaches to reduction are more
desirable with 0 RIF reserved for fractures that cannot be stabilized by less invasive methods.
If internal fixation is necessary under age 13, an
understanding of tooth bud position and the role
for monocortical screw placement is essential.
In nasal injuries, septal hematoma should be ruled
out and edema may require observation to assess for
displaced bones.
Nasooroitoethmoid fractures should be suspected
with high force traumas, dorsal nasal flattening. or
CSF rhinorrhea.
Associated neurocrania! injuries are more common
in the pediatric trauma patient and should be considered during the workup.
If MMF is necessary, it should be limited to 2 to
3 weeks, followed by 6 to 8 weeks of elastic bands.
Orbital fractures should consider muscular entrapment where early surgery is indicated. Observation
may be appropriate in other isolated injuries.

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