Scalp Laceration, Skull Fractures, and Facial Fractures

Complex skull and facial injuries are usually complicated by a compromised airway.

Contributing factors

• ■

  Head injury with diminished level of consciousness

• ■

  Alcohol, and/or drug intoxication

• ■

  High risk of aspiration

• ■

  Presence of broken teeth, dentures, foreign bodies, avulsed tissues

• ■

  Multiple mandibular fractures

• ■

  Massive edema of glottis

• ■

  Maxillofacial injury where there is constant risk of the displacement of tissue, bleeding, and swelling

Consider airway protection and early definitive airway.

• ■

  Nasotracheal intubation is not indicated in comminuted midface or skull base injury.

• ■

  Nasotracheal intubation may be indicated in the injury of lower face, or where mouth opening is inadequate.

• ■

  Traction movements during intubation may increase the risk of bleeding and associated damage.

• ■

  Bag-mask ventilation may be potentially hazardous in Le Fort type II, Le Fort type III, and nasoethmoidal fractures with suspected fracture of the anterior cranial fossa due to risk of:

  • ■

    forcing infectious material into a basilar skull fracture.

  • ■

    displacing nasal debris and foreign particles into the brain.

  • ■

    tension pneumocephalus due to associated dural tear with basilar skull fracture leading to rapid deterioration of neuro status.

C-spine protection

• ■

  Complex maxillofacial trauma has a high risk of associated cervical spine fracture.

• ■

  Almost 15% of skull fractures are associated with cervical spine injury.

Sources of massive bleeding

• ■

  Maxillofacial fractures

  • ■

    Cause oral and nasal bleeding

  • ■

    Source of bleeding may be from ethmoid artery, ophthalmic artery, vidian branch of maxillary artery

  • ■

    Most bleeding is easily controlled, but rarely, severe epistasis from the maxillary artery, may be difficult to control.

• ■

  Skull base fractures, and laceration of pharynx causing oral bleeding

• ■

  Scalp laceration

Methods to control bleeding

• ■

  Extraoral/face/scalp laceration

  • ■

    Pressure at the bleeding site(s)

  • ■

    Repair of laceration

  • ■

    Suture ligation of bleeders

• ■

  Nasal bleeding due to maxillofacial fracture

  • ■

    Pressure packing: First choice is usually anterior and posterior packing.

  • ■

    Balloon tamponade using Foley catheter

    • ■

      Balloon tamponade should be used with caution in comminuted midface fracture because it may cause displacement of fractured fragment into orbits and brain.

  • ■

    Manual reduction of fractures

  • ■

    Selective angioembolization for continued bleeding control with packing

    • ■

      Complications

      • ■

        Cranial nerve VII palsy

      • ■

        Trismus

      • ■

        Necrosis of tongue

      • ■

        Blindness

      • ■

        Migration of emboli into internal carotid, and eventually stroke

  • ■

    Direct external carotid artery (ECA) ligation

    • ■

      May be ineffective in nasoorbital ethmoidal fracture due to collaterals from the internal carotid artery

Layers of the scalp from superficial to deep

• ■

  S: Skin

• ■

  C: Connective tissue: dense tissue with vessels and nerves

• ■

  A: Aponeurosis: galea (aponeurosis of occipitofrontal muscle)

• ■

  L: Loose areolar tissue: emissary veins (dangerous zone for extracranial and intracranial infections)

• ■

  P: Pericranium

Deep lacerations may result in massive bleeding from the vessels between galea and deep dermal layer, leading to hemorrhagic shock.

Galea must be repaired to prevent:

• ■

  facial asymmetry and asymmetrical facial expression in frontal scalp laceration.

• ■

  subgaleal infections leading to diffuse scalp infection.

Technique of scalp laceration repair

• ■

  Galea is involved in:

  • ■

    single-layer repair including both galea and skin together with sutures.

  • ■

    two-layers repair: repair of galea with 3/0 or 4/0 absorbable sutures (Vicryl or Monocryl) followed by skin closure with sutures or staples.

• ■

  Simple scalp laceration

  • ■

    Repair with staples or sutures.

• ■

  Significant tissue loss

  • ■

    May require Z-Plasty or other plastic surgery techniques

Based on anatomical location

• ■

  Basilar skull fracture

• ■

  Skull vault fracture

Based on fracture lines/fragments

• ■

  Linear

• ■

  Comminuted

Based on overlying wound

• ■

  Open (compound)

• ■

  Closed

Based on degree of displacement

• ■

  Nondisplaced

• ■

  Displaced (depressed)

Vascular injuries

• ■

  Arterial dissection, occlusion, or rupture

• ■

  Arterial epidural hematoma (EDH): middle meningeal artery injury in squamous temporal bone fracture

• ■

  Arteriovenous fistula (e.g., caroticocavernous fistula)

• ■

  Dural venous injury

• ■

  Venous EDH

• ■

  Dural venous sinus thrombosis

  • ■

    Common in patients with fractures extending to a dural venous sinus or the jugular foramen

Cerebral hemorrhagic contusion

Extension through cranial nerve foramina or canals with neural damage

Dural tear leading to cerebrospinal fluid (CSF) leak and intracranial hypotension

Linear skull fracture

• ■

  Most common

• ■

  Involves full thickness of the skull from the outer to the inner table

• ■

  Complications

  • ■

    Suture diastasis

  • ■

    Venous sinus thrombosis

    • ■

      If fractures involve venous sinus groove

    • ■

      Frontal bone fracture associated with frontal sinus thrombosis

  • ■

    Epidural hematoma

    • ■

      If fracture involves vascular channels

    • ■

      Temporal bone linear fracture commonly associated with middle meningeal artery causing EDH; rare in elderly, likely due to adherence of dura to the bone

  • ■

    Cerebral contusion

  • ■

    Subarachnoid hemorrhage

Depressed skull fracture

• ■

  Bone fragments depressed inward into the cerebral parenchyma

• ■

  High risk of associated injuries to the meninges, blood vessels, and brain

• ■

  Complications

  • ■

    High incidence of compound fractures

  • ■

    Seizures

  • ■

    Neurological deficit

  • ■

    Intracranial hematoma

  • ■

    Venous sinus thrombosis

Diastatic fracture

• ■

  Fracture through the sutures of the skull

• ■

  Common in infants and children under age 3 where sutures are not fused.

• ■

  In adults

  • ■

    Usually caused by severe injuries

  • ■

    Mainly affects the lambdoidal suture because this suture fuses late

  • ■

    May cause widening of the suture and collapse of the surrounding bones

Basilar skull fractures

• ■

  Linear factures at the base of the skull

• ■

  Common in severe head injury

• ■

  Manifestations/complications of basilar skull fractures

  • ■

    Anterior cranial fossa

    • ■

      CSF rhinorrhea due to dural tear

    • ■

      Periorbital ecchymosis (raccoon eyes) due to blood leakage from the fracture site

    • ■

      Blood in the sinuses

  • ■

    Middle cranial fossa

    • ■

      Retroauricular ecchymosis (Battle sign) due to bruising of the mastoid process

    • ■

      CSF otorrhea: cerebrospinal fluid leak from the ear due to tear in dura

    • ■

      Otorrhagia: bleeding from external acoustic meatus

    • ■

      Sensorineural hearing loss

    • ■

      Facial palsy due to facial (cranial nerve VII) injury

• ■

  Posterior cranial fossa

  • ■

    Occipital condyle fracture

    • ■

      Asymmetry in tongue protrusion due to cranial nerve XII injury

  • ■

    Clivus fracture

    • ■

      Most anterior portion of the basilar occipital bone

    • ■

      Problem with abduction of eye movement due to cranial nerve VI palsy.

  • ■

    Transsphenoidal basilar fracture

    • ■

      Internal carotid artery injury

    • ■

      Carotid-cavernous fistula

    • ■

      Cranial nerve injury including optic cranial nerve injury (cranial nerve II), oculomotor (cranial nerve III), trochlear (cranial nerve IV), and abducens (cranial nerve VI)

    • ■

      High incidence of dural tear with CSF leak

    • ■

      Cerebral venous thrombosis involving dural venous thrombosis, cortical vein thrombosis, and deep cerebral vein thrombosis

Compound skull fracture

• ■

  Associated with:

  • ■

    scalp laceration.

  • ■

    CSF otorrhea or rhinorrhea due to meningeal tear.

  • ■

    involvement of paranasal sinuses.

  • ■

    intracranial air (pneumocephalus).

• ■

  High risk of meningitis

Temporal bone fracture

• ■

  Fracture of squamous part may cause epidural hematoma due to middle meningeal artery injury.

• ■

  Features of fracture of the Petrous part

  • ■

    Retroauricular ecchymosis (Battle sign) due to bruising of the mastoid process

  • ■

    CSF otorrhea: cerebrospinal fluid leak from the ear due to tear in dura

  • ■

    Otorrhagia: bleeding from external auditory canal

  • ■

    Injury to ear ossicles leading to deafness

  • ■

    Facial palsy due to facial (cranial nerve VII injury

  • ■

    Trigeminal nerve (cranial nerve V) injury: Fracture of the tip of the petrous temporal bone may involve the Gasserian ganglion of the trigeminal nerve.

  • ■

    Injury to otic capsule

    • ■

      Sensorineural hearing loss

    • ■

      Vestibular dysfunction including vertigo, and balance disturbance

  • ■

    Posttraumatic cholesteatoma

• ■

  Computed tomography (CT) of the temporal bone is the imaging of choice.

Occipital condyle fracture

• ■

  May cause lower cranial injuries including glossopharyngeal nerve (IX), vagus nerve (X), accessory nerve (XI), and hypoglossal nerve (XII)

• ■

  May have associated cervical spine fracture

• ■

  May be unilateral or bilateral

• ■

  May result in occipitocervical dissociation (atlantooccipital dislocation)

  • ■

    Occipital condyle articulates with lateral mass of C1 (atlas) vertebra, which is stabilized by:

    • ■

      atlantooccipital joint capsule ligament (anterior and posterior atlantooccipital ligaments)

    • ■

      lateral atlantooccipital ligaments

    • ■

      alar ligaments (dens to each occipital condyle)

    • ■

      apical dental ligament

• ■

  CT scan is the best imaging for the evaluation of fracture.

• ■

  MRI is recommended to evaluate spinal cord and ligament injuries.

• ■

  Classification

  • ■

    Based on the mechanism of injury (Anderson and Montesano classification)

    • ■

      Type I

      • ■

        Nondisplaced comminuted

      • ■

        Impaction fracture of occipital condyle

      • ■

        Associated with axial compression injury

      • ■

        Stable fracture

    • ■

      Type II

      • ■

        Basilar skull fracture extending into occipital condyle

      • ■

        Associated with direct blow to lower skull

      • ■

        Stable injury

    • ■

      Type III

      • ■

        Condylar avulsion fracture at the alar ligament attachment

      • ■

        Caused by forced contralateral bending and rotation

      • ■

        Potentially unstable injury

  • ■

    Clinical classification (Tuli classification):

    • ■

      Type I: nondisplaced fracture; does not require stabilization

    • ■

      Type II: displaced fracture

      • ■

        IIA: no ligamentous instability; treated with external stabilization

      • ■

        IIB: ligamentous instability; should be treated with surgical fixation

Nonoperative management

• ■

  Nondisplaced linear fractures of the vault of skull in neurologically intact patients

• ■

  Linear basilar fractures in neurologically intact patients

• ■

  Depressed fracture over the venous sinus in neurologically intact patient

• ■

  Depressed skull fractures with depressed segment <5 mm below the inner table of adjacent bone

• ■

  Temporal bone fractures

• ■

  Types I and II (Anderson and Montesano classification) occipital condyle fractures; external stabilization with cervical collar

Operative management: indications

• ■

  Depressed fractures

  • ■

    With cosmetic deformity, such as forehead fracture

  • ■

    Depression greater than the depth of the adjacent inner table

  • ■

    Depressed segment >5 mm below the inner table of adjacent bone

    • ■

      Due to increased incidence of dural injury

    • ■

      Reduces incidence of posttraumatic seizures

  • ■

    Significant underlying hematoma

  • ■

    Open depressed skull fracture

  • ■

    Fracture over the venous sinus usually treated nonoperatively due to risk of uncontrolled bleeding but should be operated in neurologically unstable patient

• ■

  Any type of open (compound) skull fracture will significant contamination

• ■

  Fractures with pneumocephalus due to dural tear

• ■

  Basilar skull fracture with persistent CSF leak after failed nonoperative management

• ■

  Temporal bone fracture

  • ■

    Immediate facial nerve injury

    • ■

      Delayed onset or incomplete facial paralysis almost always resolves with nonoperative treatment including corticosteroids.

  • ■

    Hearing loss

  • ■

    Vestibular dysfunction

  • ■

    CSF leakage

• ■

  Occipital fractures

  • ■

    Type III (Anderson and Montesano classification) or Type IIB (Tuli classification): occipitocervical fusion

Le Fort type I fracture

• ■

  Transverse fracture just above the alveolar ridge of the upper teeth

• ■

  Causes separation of hard palate from the maxilla, causing floating palate

• ■

  Fracture lines involve:

  • ■

    pterygoid plates just above the floor of the nose.

  • ■

    inferior nasal septum.

  • ■

    lateral bony margin of the nasal opening.

  • ■

    medial and lateral walls of the maxillary sinus

Le Fort type II fracture

• ■

  Pyramidal fracture through the nasofrontal suture, nasal bones, medial-anterior orbital wall, orbital floor, inferior orbital rims, posterior maxilla, and pterygoid plates

• ■

  Causes floating maxilla

Le Fort type III fracture

• ■

  Transverse fracture of the midface that results in craniofacial dissociation, leading to floating face

• ■

  Separates the maxilla from the skull base

• ■

  Fracture line passes through the nasofrontal suture, medial orbital wall, zygomaticofrontal suture, zygomatic arch, maxillofrontal suture, and pterygoid plates.

• ■

  Within the nose, the fracture extends through the base of the perpendicular plate of the ethmoid air cells, the vomer, and both parts of the nasal septum.

Le Fort type I fracture

• ■

  Mobile palatomaxillary segment

• ■

  Palatal mucosal laceration

• ■

  Dislocation of maxillary teeth

• ■

  Malocclusion

Le Fort type II fracture

• ■

  Injury to infraorbital nerve, resulting in reduced sensitivity in the frontal teeth, upper lip, cheek, and skin of the lateral nose

Le Fort type III fracture

• ■

  Oral and nasal bleeding

• ■

  Malocclusion

• ■

  Orbital edema

• ■

  CSF rhinorrhea

• ■

  V2 branch of trigeminal nerve injury

• ■

  Olfactory nerve injury