Fractures of the Cranio-Orbital and Midfacial Skeleton

History of present illness

• a.

  A detailed history of the mechanism(s) of injury clarifies the extent of injury and the potential for secondary injuries to other structures or body systems. The history of the injury may need to be obtained from friends or family.

• b.

  Advanced trauma life support (ATLS) protocols should guide the evaluation of the injured patient.

• c.

  The potential for head injury should not be ignored, particularly in those who have a loss of consciousness. Concussion should be considered in the differential diagnosis after significant injury to the head and neck region and concussion protocol initiated.

• d.

  A history of previous facial injury or facial dysplasia/deformity is important when understanding the extent of injury and the precise goals for reconstruction.

A full examination of the head and neck is performed to identify any soft tissue, bone, or visceral injuries. Particular attention is given to specialized structures such as the brain, cranial nerves, globe, lacrimal system, and other important anatomic structures that may have been injured in conjunction with facial injuries.

A complete ophthalmologic examination is helpful when injuries are apparent in the region. At times, a skilled Ophthalmologist may help in performing additional specialized examinations of the cornea, retina, globe integrity and position, or lacrimal system.

A detailed neurologic examination can clarify the extent of injury to the brain and spinal cord and may help not only in the primary assessment but also during follow-up. Preoperative assessments using concussion evaluation tools such as the IMPACT assessment tool can clarify functional deficits in cognition.

After eliciting a historical understanding of the patient’s occlusion, a detailed evaluation of the bite, excursions, maximal opening, and deviation is essential to understand maxillary fractures and their involvement with adjacent areas such as the injured or uninjured mandible.

Only select injuries with little or no chance of concomitant injuries are treated by physical examination without imaging, such as the isolated nasal fracture. However, most other facial injuries are evaluated using a high-quality spiral computed tomography (CT) formatted in axial, sagittal, coronal, and three-dimensional views. Performing these scans in a manner consistent with navigation and computer-assisted surgery protocols with files saved in digital imaging and communications in medicine (DICOM) format is helpful, and additional technology may be used. CT angiography is helpful for larger caliber vessels, but it is still inadequate for imaging of the smaller vasculature in most areas of the craniomaxillofacial region.

Rarely, interventional radiologic techniques can be helpful for treating bleeding vessels that cannot be addressed through typical surgical exposures. Traumatic arterial dissections or bleeding arteries at the cranial base may be addressed with interventional techniques using superselective embolization or other methods.

Displacement of the cranio-orbital or midface bones that cause either aesthetic imbalance and/or functional impairment such as a blocked naso-lacrimal system, diplopia, ocular muscle entrapment, or malocclusion

Decision making regarding the timing of operative intervention is typically regarded as most effective in the early phase of healing. Delayed repair can be associated with increases in infection rates and difficulty with accurate reduction of fragments due to early remodeling.

There are many approaches to the cranio-orbital and midface regions, and each presentation requires a customized approach based on complexity and the need for exposure to achieve accurate reduction and fixation. There is significant variability in surgical techniques for each of these procedures. The most common examples are described as follows.

Medical and/or traumatic comorbidities with increased risk for general anesthesia

Significant uncorrected bleeding disorder or nutritional deficiency that would increase risk for complication with wound healing

Critical injury to the brain or other structures that would be worsened with an open procedure in the region

Critical injury to the globe or optic nerve that would be worsened with manipulation of the contents of the orbit or surrounding region

Discontinue antiplatelet drugs or other medications that affect the ability to mount a clotting response, if possible.

Optimize hemodynamics.

Evaluation of the cervical spine to avoid worsening an existing injury and stabilization if necessary

Consider a staged approach if panfacial fractures are present to allow for reimaging and re-assessment.

Consider the use of navigation or intraoperative CT to ensure that the proper equipment is available and that positioning can accommodate the technique desired.

Blood products may be considered if extensive fractures requiring complex, lengthy approaches are required.

Patients should be counseled on postoperative care including pain management, dietary and activity restrictions, and possible need for secondary revision procedures.

General: These procedures are routinely performed under general anesthesia with the patient orotracheally or nasotracheally intubated. Occasionally, a tracheostomy is needed for airway management. Often, swelling limited to the face does not impact airway dynamics significantly and is manageable without the use of a tracheosotomy. The decision to manage the occlusion is typically the key variable when considering oral versus another route of intubation.

Selective hypotension is helpful to avoid excessive blood loss.

Supine with full access to the head

If intraoperative navigation or CT is planned, then positioning of the patient and the operating room must accommodate these techniques properly.

A horseshoe-ring headrest can be used for more complete access to the skull.

A shoulder roll is often helpful for slight extension of the neck if cervical spine injury has been ruled out.