HEAD AND NECK
The management of facial
trauma
Robert Stuart McCormick
Graham Putnam
Abstract
Facial or maxillofacial trauma occurs as a consequence of physical
injury to the face and can include damage to soft tissue and bony
structures either in isolation or combination. There is a male predom-
inance with highest incidence in the age group of 20e40 years. The
range of injuries include soft tissue damage, bruising, lacerations,
burns and fractures of the underlying facial skeleton including the
zygomatic complex, mandible, maxilla, orbit and nasoethmoidal com-
plex. The concentration of special senses in the head and neck region
means that even seemingly minor injuries can have a significant
impact upon the long-term outcome for a patient. Careful assessment
of an injured patient must include a full ATLS evaluation to ensure that
associated potentially life-threatening injuries are not missed. This
article describes the signs, symptoms and treatment of maxillofacial
trauma, including management of hard and soft tissue trauma.
Keywords Hard tissue facial injuries; mandibular fractures; maxillary
fractures; maxillofacial trauma; soft tissue facial injuries; zygomatic
fractures
Introduction
Maxillofacial injuries are common. The causative factors of facial
injury have changed in developed countries in recent years from
predominantly motor-vehicle accidents to interpersonal violence
as the major aetiological factor. The association of alcohol with
interpersonal violence and consequently facial injury is signifi-
cant.1 Social policy, legislation and changing of group behaviours
are required to influence the actions that lead to interpersonal
violence. The introduction of drink-driving and seat belt legis-
lation, improved driving and road conditions and the advance-
ment in the safety features of modern vehicles has led to a fall in
maxillofacial injuries attributable to road traffic accidents (RTAs)
in the developed world. Falls, particularly in the elderly, is an
increasing problem and has been attributed to the trend towards
ageing populations in advanced nations.
Initial assessment
Careful initial assessment of the injured patient is imperative.
Patients may present with simple minor facial injuries or
potentially life-threatening ones and ATLS principles should be
Robert Stuart McCormick BDS MFDS MBBS MRCS is a Specialty
Trainee in the Northern Deanery, UK. Conflicts of interest: none
declared.
Graham Putnam BDS FDSRCS MBBCh FRCS is a Consultant OMFS/
Head and Neck Surgeon at North Cumbria University Hospital NHS
Trust, Carlisle, UK. Conflicts of interest: none declared.
SURGERY 36:10
utilized with primary and secondary surveys and careful
assessment of the airway with appropriate intervention if
required. Severe life threatening bleeding can occur as a result of
facial trauma and its management should take priority over
definitive fracture fixation.
Soft tissue injuries
These range from simple oedema, haematoma, lacerations,
abrasions, puncture wounds, wounds associated with thermal,
chemical or blast damage as well as human and animal bites.
With the cranialization of specialist senses in the head and
neck region careful assessment should be made of the potential
for damage to underlying structures such as the lacrimal appa-
ratus, the facial nerve and major salivary gland ducts. Addi-
tionally, assessment should be made of intraoral and intranasal
structures to ensure their integrity. Whilst the soft tissue injury
may be the most visible element of trauma, an appropriate
assessment should be made of the underlying bony structures to
facilitate a full assessment of the patient.
Special mention should be made of scalp lacerations, which
have a propensity for degloving, leading to significant blood loss
and haematoma formation. Closure of this type of laceration may
require the use of vacuum drainage and pressure dressings to
reduce the incidence of post-treatment haematoma.
The muscles of facial expression are unique in that rather than
being inserted into bone they are attached to skin and thereby
facilitate the extensive range of facial expression that humans are
capable of. When a facial laceration occurs this can lead to
marked separation of wound edges giving the impression of tissue
loss. Whilst tissue loss is possible in facial injury a careful
assessment and mobilization of tissues should be carried out to
ensure that the perceived tissue loss is not just in fact tissue
separation. The excellent blood supply of facial tissues means that
extensive tissue debridement is rarely necessary and attempts at
tissue preservation should be considered, where possible.
The aesthetic importance of the face cannot be over-
emphasized and in the presence of lacerations great care should
be taken in appropriate approximation of the tissues. Following
debridement and antiseptic cleansing of the wounds, careful
approximation of the distinct soft tissue layers should be made
utilizing a resorbable suture for deep layers and a fine mono-
filament suture for skin. Where a laceration crosses an important
aesthetic unit such as the vermilion portion of the lip the first
skin suture should be placed at the junction to ensure accurate
alignment. Early suture removal reduces the epithelial ingrowth
along suture tracts and improves the aesthetic outcome. The use
of tissue adhesives may be suitable in some circumstances.
If following assessment it is considered that damage to the
important underlying structures has occurred then specialist
referral should be made.
Antibiotics are not generally indicated in the management of
simple uncomplicated lacerations. However, if a wound has
significant contamination or has been caused by a human or
animal bite then antibiotics should be used to reduce the inci-
dence of postoperative infection.
Soft tissue injuries can also occur to the intraoral tissues and
laceration to vascular structures such as the tongue can lead to
significant bleeding. Degloving injuries can occur around the
587 Ó 2018 Elsevier Ltd. All rights reserved.
 HEAD AND NECK
maxilla and mandible and may be difficult to reapproximate
without causing scarring in the vestibular tissues.
Dentoalveolar injuries
Dentoalveolar injuries occur to the tooth-bearing portions of the
jaws. They commonly occur in children and are often associated
with sports activity. Trauma to the intrinsic structure of teeth
should be referred to a general dental practitioner for management.
Management of avulsed permanent teeth2
 Ensure the avulsed tooth is a permanent tooth.
 Immediate replantation is the best treatment at the scene of
the accident. If the tooth is contaminated washing it briefly
and gently under running water without touching the root
should be carried out prior to replantation.
 Immediate dental attention should be sought to splint the
replanted tooth
 If the tooth cannot be immediately replanted it should be
stored in a glass of milk before seeking dental attention.
Management of dentoalveolar fractures
 A fracture of the tooth bearing bone of the jaw.
 Segment mobility and dislocation with several teeth mov-
ing together are common findings.
 The displaced segment should be repositioned and splinted
paying attention to the occlusion. Adjacent teeth can be
utilized for splinting.
Hard tissue facial trauma
The facial bony anatomy can be divided into upper, middle and
lower facial thirds. The upper third comprises the frontal bone
and sinus. The middle third is made up of the orbits, zygomatic
bones, nasal bones and maxilla. The lower third comprises the
mandible. Fractures involving two or more facial thirds are
known as panfacial fractures.
The severity of an injury is proportional to the mass of the object
that hits the face and the speed at which it comes into contact, ki-
netic energy (the energy required to accelerate a given mass to a
given velocity). High kinetic energy trauma (such as RTAs) tend to
result in a greater extent of facial injury, leading to panfacial
trauma or fractures to the midface and frontal regions. A commi-
nuted fracture pattern tends to be the norm. In contrast, low kinetic
energy injuries such as the use of a fist or a bottle in the more
common forms of interpersonal assault leads to more localized
fractures to the nasal bones, mandible, zygoma and orbital regions.
Fractures are commonly classified anatomically. Additional
considerations include whether the fracture is simple or com-
pound, displaced/undisplaced, comminuted (the bone is frac-
tured into several segments), greenstick (involving only one
cortex e common in paediatric cases), pathological (has
occurred secondary to a disease process or lesion in the line of the
fracture) or complex/complicated (when there is involvement of
other non-bony structures, e.g. neural or vascular structures).
General assessment
A history of the mechanism of injury may help to determine a
specific fracture pattern and identify concomitant injuries
SURGERY 36:10
common to facial fractures such those to the eye, cervical spine
or brain. It may also help identify concerning mechanisms such
as in the elderly who have fallen and require further evaluation.
Many patients presenting with such injuries have been
assaulted and for medicolegal purposes it is important to have
contemporaneous documentation of the circumstances sur-
rounding an alleged assault in the event that the medical team
are approached by the police for witness statements in the future.
It is important to exclude hard tissue trauma in situations that
may initially appear to affect the soft tissues alone. Examination
should include those structures that can be injured in association
with fractures to the maxillofacial skeleton. Assess for the pos-
sibility of cranial, base of skull or intracranial injury. Palpate the
cranium and bony facial skeleton for tenderness, boggy swelling,
step deformity or depressions particularly at the orbital rims,
zygoma, zygomatic arches, bridge of nose and at the lower
border of the mandible. Look for nasal deformity and deviation.
In the presence of nasal fracture, remember to exclude the
presence of a septal haematoma.
Bleeding from the external auditory canal may be a feature of
a fracture to the mandibular condyle or haemotympanum in
association with a base of skull fracture. Visual symptoms and
signs may be a feature of orbital fractures. However, direct visual
inspection of the eyes, assessment of visual acuity, pupillary
reactions, determining the range of eye movements and for the
presence of diplopia are essential to rule out concomitant sight
threatening injuries. An intraoral examination is essential to
exclude dental injuries and assessment of the patient’s occlusion.
A focussed cranial nerve examination should be undertaken.
Mandibular fractures
Mandibular fractures represent the most common injury to the
maxillofacial skeleton, apart from simple nasal fractures. A
fracture can occur at any of the anatomical subunits which
include the mandibular condyle, coronoid process, angle, body,
parasymphysis and symphysis. The mandibular condyle is the
most common site to fracture in isolation. However, mandibular
fractures are commonly multiple with fractures to the mandib-
ular parasymphysis and angle or fractures to the mandibular
parasymphysis and condyle being the most common
combinations.
Symptoms include pain, swelling, restricted jaw movements,
restricted mouth opening (trismus), inability to close the teeth
together completely and abnormalities to the bite (occlusion).
Specific signs of mandibular fractures include the presence of a
sublingual haematoma (seen with symphyseal/parasymphysis
fractures), steps or mobile segments within the mandibular
dental arch, altered occlusion and anaesthesia/paraesthesia in
the distribution of the mandibular division of the trigeminal
nerve, presenting as a numb lip.
A Guardsman’s fracture is a specific fracture pattern in the
mandible that occurs when the force that results in fracture is
focussed at the mandibular symphysis. This results in fractures at
the symphysis and bilateral condyles. This is commonly seen
following an unexplained collapse in elderly patients who fall
without an attempt to save themselves with outstretched hands.
They characteristically present with a sublingual haematoma and
an abnormal occlusion manifesting as an anterior open bite
588 Ó 2018 Elsevier Ltd. All rights reserved.
 HEAD AND NECK
(shortening of the fractured condyles results in premature pos-
terior contact between upper and lower dental arches and a gap
between the arches anteriorly).
Plain imaging taken at two different planes (preferably at right
angles to each other) is most commonly used for diagnosis.
Panoramic imaging by way of an orthopantomogram (OPG) and
posterior to anterior (PA) mandible are the modalities of choice.
In the context of blunt major trauma the mandible is often
imaged during the taking of a whole body computed tomogram
(CT). However, plain films are still useful for management of the
fractures (Figure 1a and b).
Reduction of the fracture, immobilization/fixation and reha-
bilitation are the fundamental principles of fracture management
in general and also apply to mandibular fractures. In most
routine fractures involving the symphysis, parasymphysis, body
or angle of mandible, treatment is by open reduction and internal
fixation (ORIF). Unlike orthopaedic practice, rigid fixation is not
required in the majority of cases. Therefore, semi-rigid fixation,
using titanium miniplates and monocortical screw fixation is
utilized. This technique relies on ideal conditions for healing and
Figure 1 (a) Orthopantomogram (OPG) demonstrating fracture of the right parasymphysis and left ramus of mandible. (b) Posterior-anterior (PA)
mandible demonstrating same fracture pattern as OPG.
SURGERY 36:10
good contact between bone fragments. This is often undertaken
via an intraoral approach and general anaesthesia. In certain
cases, such as severe comminution, edentulous mandibles or in
infected cases, rigid fixation is required with the use of thicker
profiled plates and bicortical screws. This usually requires
greater access than intraoral methods allow and an extraoral
approach to more widely expose the mandible may be required.
The use of ORIF allows for earlier rehabilitation of the mandible.
However a soft diet is recommended for 4 weeks and avoidance
of contact sport for 3 months. In a minority of cases, undisplaced
fractures may be managed conservatively by way of soft diet.
Fractures of the mandibular condyle
Mandibular condyle fractures are generally managed conserva-
tively if undisplaced. In the presence of displacement, the height
of the mandibular ramus will shorten and results in a malocclu-
sion. In unilateral cases this results in premature occlusal contact
ipsilaterally. In bilateral condylar fractures the patient presents
with an anterior open bite. Closed reduction is achieved by
589 Ó 2018 Elsevier Ltd. All rights reserved.
 HEAD AND NECK

placement of arch bars held around the maxillary and mandibular In 1901, the French surgeon, Rene Le Fort, classified fractures
dental arches with circumdental wires. Bone anchored screws can to the maxilla and midface when he experimentally induced
also be used. Postoperatively elastic traction is used between fractures in cadavers following the application of variable de-
these devices to re-establish the patient’s normal occlusion. This grees of blunt force. He described three fracture patterns, Le Fort
is known as maxillomandibular fixation (MMF). I, II and III, resulting from a force of different magnitude and
Contemporary evidence-based practice is to treat displaced resulting in variable degrees of craniofacial dissociation. Le Fort
condylar fractures by open reduction and internal fixation as this I, the lowest fracture pattern, is a fracture of the tooth bearing
leads to a better anatomical reduction as well as improved portion of the maxilla and extends horizontally from the ptery-
function. Patients have a better range of mandibular movements, goid plates though the lateral walls of the maxillary antra to the
less trismus and less pain at 6 months compared to when piriform aperture of the nose. Le Fort II fractures, also known as
managed with MMF.3 There are various surgical approaches to pyramidal fractures, run in a superoanterior direction from the
the condyle which may be via an external or intraoral approach. pterygoid plates, through the inferomedial orbital floor before
The important risks include scarring, a low risk of temporary or terminating at the nasal bridge. The highest fracture pattern, Le
permanent facial nerve palsy, Frey’s syndrome and sialocoele Fort III, results in complete craniofacial dysjunction of the mid-
formation. face from the skull base. The fracture traverses the nasofrontal
suture and travels laterally to involve the medial and lateral or-
Nasal fractures bits and the zygomatic arches. In reality, fracture patterns are
more complicated in that they are often asymmetric and at
Nasal fractures are by far the most common facial fracture. Most
multiple levels. Therefore, when the Le Fort classification is used
are the result of lateral blunt forces resulting in unilateral or
in clinical practice it is used to describe the highest level of
bilateral fractures to the nasal bones and frontal processes of the
fracture on each side of the face (Figures 2e5).
maxilla. Frontal blunt force results in posterior displacement/
As fractures to the midface require significant force, they often
impaction. A quarter of nasal fractures occur in children who
present in the severely injured patient. Rarely, they have acute
have mainly cartilaginous noses. Combined with open bony su-
life-threatening consequences. When they do, bleeding, swelling
tures this results in an open book fracture and a flattened nose.
and displacement of the fracture can manifest with airway
Septal fracture is often overlooked during assessment and neglect
compromise or significant haemorrhage, requiring immediate
in its management often results in secondary deformity. External
medical attention. Typically, management is delayed until other
assessment includes a visual inspection and palpation to deter-
life-threatening injuries are stabilized. Such injuries present with
mine the pattern of deviation, presence of bony steps or lacera-
marked midface swelling and ecchymosis.
tions and to exclude more complex injury such as a
As swelling subsides, a ‘dished face’ deformity occurs sec-
nasoorbitoethmoidal fracture. Intranasal examination using a
ondary to posteroinferior displacement of the fracture. Mobility
nasal speculum is required to exclude septal fracture and septal
haematoma which requires immediate evacuation to prevent
septal necrosis and development of secondary saddle deformity.
Epistaxis is common. However, the development of infection or
intranasal adhesions are rarer complications of injury. Radio-
graphic investigation is unnecessary in an isolated nasal fracture.
Reduction of nasal fractures is indicated if there is an obvious
cosmetic deformity, a functional problem with breathing, or as
part of the management of a post-traumatic epistaxis. This is
usually delayed for a week to allow for swelling to settle which
can mask deformity or be the cause of breathing impairment.
Most nasal fractures are manipulated by a closed technique. This
can be done under local or general anaesthetic using digital
pressure with or without specialized instruments. Open reduc-
tion is reserved for unstable fracture patterns, significant septal
injury or in delayed presentation. Despite the perception that
treatment for nasal fracture is simple a number of cases go on to
require revision surgery or secondary septorhinoplasty.

Midfacial fractures
The midface is composed of rigid vertical and horizontal but-
tresses which are designed to protect the orbits, sinuses, nasal
cavity and dentition. The strength of these buttresses ensures
that these structures are well protected from fracture unless
Figure 2 Frontal view of the craniofacial skeleton. Demonstrates fix-
substantial force is applied. Typically, these injuries tend to be
ation of panfacial fractures at Le Fort I, II and III levels in addition to a
the reserve of significant blunt trauma, often associated with comminuted fracture of the mandibular symphysis. (After Assael LA
panfacial fracture patterns and when there are other major et al. Manual of Internal Fixation in the Cranio-facial Skeleton, 1998.
concomitant injuries. With kind permission of Springer Verlag).

SURGERY 36:10 590 Ó 2018 Elsevier Ltd. All rights reserved.

 HEAD AND NECK
Figure 3 Frontal view of the craniofacial skeleton. Demonstrates a
fracture at the Le Fort III level on the right and a combination of Le Fort
II and III fractures on the left. (After Assael LA et al. Manual of Internal
Fixation in the Cranio-facial Skeleton, 1998. With kind permission of
Springer Verlag).
of midfacial structures and altered sensation to the upper lip may
be observed. If there is variation in the level of fracture on the
contralateral side a midline split can affect the palate. Typically,
the occlusion is deranged. An anterior open bite is the common
abnormality secondary to posteroinferior displacement of the
midface.
Fine sliced computed tomography (CT) is the imaging of
choice to help determine the fracture pattern. Reformatting into
three dimensional images is useful in planning subsequent
treatment.
Definitive treatment is ideally around 7 days following injury.
This allows time to determine prognosis, particularly when there
is an associated head injury. Practically, this allows swelling to
settle making surgical repair easier and more accurate, particu-
larly when considering access through transcutaneous or trans-
conjunctival periorbital incisions for higher fracture patterns.
Consideration of airway management during treatment is
required, nasal intubation should be used for low level fractures,
but for higher fractures a tracheostomy may be required if nasal
intubation cannot be achieved safely. Oral intubation prevents
the re-establishment of the correct occlusion. Higher fracture
patterns and greater comminution usually necessitates wider
SURGERY 36:10
Figure 4 Frontal view of the craniofacial skeleton. Demonstrates in-
ternal fixation of fractures at the Le Fort III level on the right and to the
combination of Le Fort II and III fractures on the left. (After Assael LA
et al. Manual of Internal Fixation in the Cranio-facial Skeleton, 1998.
With kind permission of Springer Verlag).
exposure. Le Fort I/II fractures with minimal comminution are
accessed with a combination of intraoral circumvestibular inci-
sion in the maxillary sulcus and either transcutaneous or trans-
conjunctival incisions periorbitally to access the orbital rims.
Higher fracture patterns with severe comminution require the
addition of a coronal flap to gain access to the zygomatic arches,
lateral and medial orbits as well as the nasofrontal region. Fix-
ation is by means of titanium miniplates and monocortical
screws positioned along the main vertical and horizontal but-
tresses of the midfacial skeleton where bone stock is at its
strongest and thickest. Elastic traction using MMF is often
required and a soft diet employed in the postoperative period.
Zygomatic complex fractures
Isolated fractures of the zygomatic complex are common and are
frequently associated with interpersonal violence. A fracture of
the zygomatic complex occurs when any of the five articulations
of the zygoma with the craniofacial skeleton occurs. Separation
at the zygomaticofrontal suture, infraorbital rim, zygomatico-
maxillary buttress, zygomaticotemporal suture (arch) and the
zygomaticosphenoid suture commonly occur in a ‘simple’
zygomatic fracture.
591 Ó 2018 Elsevier Ltd. All rights reserved.
 HEAD AND NECK
Figure 5 Oblique view of the craniofacial skeleton demonstrating a
fracture of the left zygomatic complex. Points of dysjunction in zygo-
matic fractures include at position 1 (frontozygomatic suture), position
2/3 (zygomaticomaxillary suture), position 4 (zygomaticotemporal su-
ture) and position 5 (zygomaticosphenoid suture). (After Assael LA
et al. Manual of Internal Fixation in the Cranio-facial Skeleton, 1998.
With kind permission of Springer Verlag).
Clinically, a displaced fracture will result in facial asymmetry
and flattening of the malar prominence once any acute swelling
subsides. As a fracture propagates through the infraorbital fora-
men, patients will often present with altered sensation to the
ipsilateral upper lip and maxillary dentition. Impingement of the
displaced zygoma against the coronoid process of the mandible
results in trismus and inability to perform lateral excursive
movements. The zygoma is one of seven bones that make up the
orbit. Zygomatic fractures will inevitably result in fracture of the
orbital floor. With significant displacement this may manifest
with an increased orbital volume, diplopia and altered globe
position resulting eventually in enophthalmos.
The close proximity of the zygomatic complex and orbit to the
visual apparatus results in a significant proportion of patients
with fractures also presenting with ocular injuries. A proportion
of these will be serious enough to result in a risk to sight. It is
vital that patients with suspected zygomatic or orbital injuries are
examined for visual symptoms and signs with referral to
ophthalmology if concerns are highlighted.4
Retrobulbar haemorrhage is a rare but sight-threatening
complication of orbital trauma, anaesthesia or surgery. It is one
of several causes of an orbital compartment syndrome. Bleeding
within the closed compartment of the orbit will result in
decreased perfusion resulting in optic nerve and retinal
ischaemia. This is irreversible after 60 minutes. Pain, proptosis, a
SURGERY 36:10
dilated pupil, loss of direct reflex, relative afferent pupillary
defect, reduced visual acuity, ophthalmoplegia and loss of red
colour saturation are the cardinal features. Ophthalmoscopy may
show a pale and swollen disc. This is a clinical diagnosis and if
suspected, immediate decompression is required via a lateral
canthotomy and inferior cantholysis under local anaesthetic.
Diagnostic imaging should not delay decompression.
Zygomatic fractures are usually diagnosed with use of plain
radiography facial views. These include occipitomental and
submentovertex views. Often, due to associated injuries in
trauma patients, these injuries are picked up on CT.
Not all fractures require repair. Undisplaced fractures can be
managed conservatively. Patients are advised to avoid nose
blowing to prevent the development of surgical emphysema in
the periorbital region and to avoid lying on the injured side.
Fractures resulting in facial asymmetry, restriction of mandibular
movements or visual symptoms require treatment. Closed
reduction methods are uncommonly used in contemporary
practice. Open reduction of a displaced fracture is achieved by
placement of an elevating device under the zygoma via either an
intraoral vestibular incision, a hook elevation or a Gillies tem-
poral approach.
Miniplate fixation is often achieved with one-point fixation at
the zygomaticomaxillary (ZM) suture via an intraoral vestibular
incision. For more unstable fracture patterns multiple point fixation
is required in addition to fixation at the ZM suture, most commonly
at the infraorbital rim and at the zygomaticofrontal suture.
Zygomatic arch fractures
Isolated zygomatic arch fractures occur at the zygomatico-
temporal suture, with the remainder of the zygomatic complex
being left intact. Displaced fractures will result in a cosmetic
dimpling defect of the overlying skin and can result in trismus
and restricted mandibular movements. Undisplaced fractures are
managed conservatively. Displaced fractures are repaired with
open reduction via a Gillies approach or an intraoral vestibular
incision, fixation is rarely required. In panfacial trauma, the
zygomatic arch is an important landmark in re-establishing the
appropriate dimensions of facial width. In such cases, open
reduction and internal fixation proceeds via a coronal incision.
Orbital fractures
The orbit is a pyramidal shaped cavity consisting of seven bones.
These include the maxilla, zygomatic complex, lacrimal bone,
ethmoid, sphenoid, frontal and orbital plate of palatine bone. The
apex is situated posteriorly and the base, anteriorly, is made from
the dense bone of the orbital rim. There are four orbital surfaces
which make up the orbital roof, floor and medial and lateral
walls. When viewed from the sagittal plane, the orbital floor is S-
shaped taking on a concave form anteriorly and a convex form
posterior to the globe. The medial wall and orbital floor medial to
the infraorbital groove are made from thin bone and are the most
common sites to fracture.5
Two common theories on how orbital fractures occur following
blunt trauma include the hydraulic and buckling theories. The
hydraulic theory postulates that force is transmitted from the
globe to the orbital walls. The buckling theory suggests force is
transmitted from the strong orbital rim to the weaker orbital walls
592 Ó 2018 Elsevier Ltd. All rights reserved.
 HEAD AND NECK
which fracture instead.6 The pattern of orbital fractures also varies
between paediatric and adult cases. Paediatric bone is more elastic
with bones returning to their original positions following initial
fracture and displacement. This results in a ‘trapdoor’ pattern of
fracture. In contrast, adult bone, being less elastic often remains
displaced following fracture, exhibiting an ‘open door’ presenta-
tion. Fractures may occur in isolation or in association with other
injuries, most commonly zygomatic fractures.
Isolated fractures to the orbital floor or medial wall in an adult
will initially present with pain and periorbital swelling, occa-
sionally making examination of the eye difficult. Further
assessment is difficult in the immediate period. Therefore, once
sight-threatening injuries are excluded, it is reasonable to assess
these patients semi-electively when swelling is settling. Alter-
ation in globe position may present with hypoglobus or enoph-
thalmos. This is usually due to changes in volume and/or shape
of the orbit. Vertical diplopia is seen with orbital floor fractures
and horizontal diplopia is typical with medial wall fracture.
Tethering of periorbital fat or intraocular muscles will result in
painful, restricted eye movements. Orbital floor fractures are
associated with altered sensation in the distribution of the
infraorbital nerve.
Fine sliced CT of the orbit is the diagnostic imaging of
choice. Objective assessment of diplopia and measurement of
eye movements should be arranged with an orthoptic depart-
ment. A Hess chart and measurement of binocular single vision
(BSV) as a percentage is useful for making treatment decisions
and assessing any objective improvement in symptoms post-
operatively.
Operative management is indicated in the presence of unre-
solving diplopia, restricted eye movements or altered globe po-
sition. Access is via periorbital transcutaneous incisions or a
transconjunctival approach. Herniated periorbital tissue is
released and the defect repaired most commonly using alloplastic
material such as titanium mesh which is shaped to restore the
normal S-shaped contour of the orbital floor. Advancements in
this field include the use of computer assisted virtual planning to
allow manufacture of a patient-specific implant to reconstruct an
orbital defect or to facilitate manufacture of a sterolithographic
model of the reconstructed orbit, from which titanium mesh can
be bent preoperatively into the desired shape. Intraoperative
navigation is becoming increasingly popular in complex cases to
verify accurate reconstruction by comparing the intraoperative
position of any reconstruction to that planned virtually.
Frontal sinus fractures
Frontal bone fractures are rare. The frontal sinus may be absent
at birth. Pneumatisation of the frontal bone arises from the
anterior ethmoidal air cells and is complete by 15 years. The
sinus drains via the frontal sinus outflow tract (FSOT) into the
middle meatus. Fractures involving the FSOT are at increased
risk of developing complications secondary to compromized
sinus function. The anterior table of the frontal sinus is thicker
and stronger than the posterior table.
Typically, fractures occur as a result of high energy mecha-
nisms and are associated with other significant injuries including
head injury, cervical spine fracture and panfacial trauma. A third
of frontal sinus fractures involve the anterior table only. Less
SURGERY 36:10
than 1% are isolated posterior table fractures. Therefore, the
majority involve both anterior and posterior table with or
without involvement of the FSOT.
The presence of significant soft tissue injury to the frontal
region and altered forehead sensation should raise the suspicion
of underlying frontal sinus fracture. Visual inspection and
palpation should be undertaken to verify the presence of any
contour defects of the anterior table and supraorbital rim. A head
or significant eye injury should be ruled out. Any clear or salty
discharge from the nose should undergo testing for beta-2
transferrin to identify a cerebrospinal fluid leak from the nose
(CSF rhinorrhoea) suggesting a dural tear secondary to a poste-
rior table fracture. Fine sliced CT will help confirm the fracture
pattern, involvement of the FSOT, involvement of the supra-
orbital rim, the degree of displacement of any fractures and the
presence of pneumocephalus or intracranial bleed.
The goals of managing a frontal sinus fracture are to create a
safely draining sinus, restore any facial contour defects and to
reduce the chances of short or long term complications arising
from such an injury. Undisplaced or minimally displaced frac-
tures of the anterior table are generally managed conservatively.
Generally, anterior table fractures with displacement greater than
the width of the anterior table or greater than 4 mm displacement
will require open reduction and internal fixation. Access is via
existing lacerations or a coronal flap. Delayed reconstruction of
contour defects can be undertaken using a patient-specific
implant. Fractures involving the posterior table are managed by a
multidisciplinary team which includes a neurosurgeon. The main
options include obliteration or cranialization for cases with sig-
nificant displacement of the posterior table, impairment of
drainage of the FSOT or a persistent dural leak. Both of these
procedures require a coronal flap, and access to the anterior
cranial fossa. There is a trend towards more conservative man-
agement with use of minimally invasive endoscopic sinus sur-
gery to restore frontal sinus ventilation.
Early complications of frontal sinus fracture include menin-
gitis and brain abscess, particularly in the presence of a posterior
table fracture and dural tear. There is no strong evidence to
recommend prophylactic antibiotics for patients with CSF leak.7
A pneumococcal vaccination is recommended for injuries
resulting in CSF leak. Delayed complications include mucocele or
mucopyocele formation, chronic sinusitis and osteomyelitis.
Naso-orbital-ethmoid (NOE) fractures
NOE fractures are uncommon. When they occur they are usually
associated with high energy mechanisms and the majority are
associated with fractures of the frontal sinus or high Le Fort
fractures. They are complex to manage.
The NOE region is the confluence of bones found between the
nose, orbit, maxilla and cranium. The anterior boundary of this
region comprises the frontal process of the maxilla, nasal process
of frontal bone, and nasal bones. The region is bounded laterally
by the medial orbital wall and posteriorly by the sphenoid sinus.
Subtle clinical signs can lead to missed diagnosis. Tele-
canthus, an increase in intercanthal distance, is an important
clinical finding. The medial canthal tendon inserts into the NOE
complex. NOE fractures commonly involve the tendon resulting
in telecanthus. Loss of nasal projection and a broadening of the
593 Ó 2018 Elsevier Ltd. All rights reserved.
 HEAD AND NECK
root of the nose may also be observed. Fine sliced CT is the
imaging modality of choice.
Undisplaced, non-comminuted fractures with an intact medial
canthal tendon can be managed conservatively. Displaced, non-
comminuted fractures require open reduction and internal fixa-
tion. Comminuted fractures or those with disruption of the
medial canthal tendon require access via a coronal approach.
Transnasal wiring or other canthopexy procedure is required to
relocate the medial canthal tendon.
Missed NOE fractures results in nasal deformity including a
shortened and retruded nasal root and signs suggestive of an
untreated medial orbital fracture.
Panfacial fracture
Panfacial fractures are those that involve multiple facial thirds.
Traditionally, this meant involvement of all three facial thirds.
However, in contemporary practice the definition applies to
those fractures involving two or more facial thirds.
These injuries typically occur in the multiply injured patient.
Special emphasis needs to be given to the appropriate timing of
intervention, airway management, access and the most appro-
priate sequencing of operative repair in panfacial trauma.
Immediate intervention is minimized in the multiply injured
patient to reduce the surgical burden on the patient. This is
restricted to management of displaced fracture patterns which
can compromise the airway or haemorrhage. Manual reduction
of midface fractures, anterior and posterior nasal packing and
surgical airways are considered. Definitive surgery is often
delayed to allow for management of life-threatening injuries and
help determine the patient’s prognosis.
A surgical tracheostomy is often required in panfacial trauma
to allow for unrestricted access to fractures at multiple levels of
the face. Nasal intubation is a possible alternative in the absence
of fractures to the upper facial third. Access is required at mul-
tiple levels. A combination of a coronal flap, transcutaneous
periorbital incisions or transconjunctival incisions and transoral
approaches are usually required.
The order in which individual fractures in panfacial trauma
cases are fixed (sequencing) is a controversial subject. There are
SURGERY 36:10
various theories, but no universally accepted technique. Common
approaches include the ‘Top-Down’ (fixation progresses from
upper to lower facial third) and ‘Bottom-Up’ (fixation progresses
from lower to upper facial thirds) approaches. There are advan-
tages to both techniques. Regardless of the sequencing method,
important considerations are restoring the posterior vertical facial
height in the presence of mandibular condyle or ramus fractures,
restoring the correct facial width in cases where the zygomatic
arches are fractured (Le Fort III) and where there is a fracture to
the mandibular symphysis. Restoring the anterioreposterior
projection of facial structures also requires consideration in
addition to careful soft tissue redraping. A
REFERENCES
1 Hutchison IL, Magennis I, Shepherd JI, Brown AE. The BAOMS
United Kingdom survey of facial injuries Part 1: Aetiology and the
association with alcohol consumption. Br J Oral Maxillofac Surg
1998; 36: 3e13.
2 Dental trauma guidelines https://www.iadt-dentaltrauma.org/1-9%
20%20iadt%20guidelines%20combined%20-%20lr%20-%2011-
5-2013.pdf.
3 Eckelt U, Schneider M, Erasmus F, et al. Open versus closed
treatment of fractures of the mandibular condylar processea pro-
spective randomized multi-centre study. J Cranio-Maxillofacial
Surg 2006; 34: 306e14.
4 AI-Ourainy I, Dutton G, Stassen L, Moos K, EI-Attar A. The char-
acteristics of midfacial fractures and the association with ocular
injury: a prospective study. Br J Oral Maxillofac Surg 1991; 29:
291e301.
5 Evans B, Webb A. Post-traumatic orbital reconstruction: anatom-
ical landmarks and the concept of the deep orbit. Br J Oral Max-
illofac Surg 2007; 45: 183e9.
6 Warwar R, Bullock J, Ballal D, Ballal R. Mechanisms of orbital
floor fractures. Ophthalmic Plast Reconstr Surg 2000; 16:
188e200.
7 Ratilal B, Costa J, Pappamikail L, Sampaio C. Antibiotic prophy-
laxis for preventing meningitis in patients with basilar skull frac-
tures. Cochrane Database Syst Rev, 2015; https://doi.org/10.1002/
14651858.CD004884.pub4. Issue 4. Art. No.: CD004884.
594 Ó 2018 Elsevier Ltd. All rights reserved.