Trauma: Head Trauma

Skull Fracture

General Surgical Repair Indications

  • Depressed > 1 cm
  • Contaminated/Infected
  • Persistent CSF Leak
  • Frontal Sinus Involvement
  • Open with Dural Penetration/Pneumocephalus
  • Significant Hematoma
  • Overlap or Violation of Inner & Outer Table

Temporal Bone Fracture

  • Most Common After Blunt Trauma
    • Occur in 30-70% of Cases Involving Blunt Head Trauma
  • Most Fractures are Longitudinal (70-80%), Transverse are Less Common
  • Complications:
    • Intracranial Hemorrhage
    • CSF Leak – Typically Resolves Within 2 Weeks
    • Meningitis – Prophylactic ABX Not Indicated
    • Hearing Loss (40%) – Higher Risk in Peds
      • Sensorineural Loss Has Worse Prognosis than Conductive Loss
    • Vertigo
    • Facial Nerve Injury & Paralysis (30-70%) – Lower Risk in Peds
  • Treatment:
    • Emergent Surgery Indications:
      • Brain Herniation into the Middle Ear, Mastoid or External Acoustic Meatus
      • Massive Bleeding from the Intra-Temporal Carotid Artery
    • Elective Surgery Indications:
      • Severe Facial Nerve Injury
      • Conductive Hearing Loss Due to Ossicular Disruption – Repair After 3 Months
        • Conductive Loss Due to Hemotympanum Typically Resolves
      • Sensorineural Hearing Loss Deemed to Be Likely to Improve Surgery (Poorer Prognosis)
      • CSF Leak > 14 Days

Skull Fracture 1

Temporal Bone Fracture 2

Basal Skull Fracture

  • Most Common After Blunt Trauma
  • Signs:
    • “Racoon Eyes”: Periorbital Ecchymosis (Anterior/Middle Fossa Fracture)
    • “Battle Signs”: Mastoid Ecchymosis (Middle Fossa Fracture)
    • Hemotympanum
    • CSF Leakage
  • Complications:
    • Intracranial Hemorrhage
    • Carotid Artery Injury or Carotid-Cavernous Fistula
    • CSF Leak – Typically Resolves Within 2 Weeks
    • Meningitis – Prophylactic ABX Generally Not Indicated
    • Cranial Nerve Injury & Paralysis
    • Cavernous Sinus Thrombosis
    • Vertigo
  • Surgery Indications:
    • Intracranial Hemorrhage
    • Vascular Injury
    • Severe Cranial Nerve Injury
    • Persistent CSF Leak > 2 Weeks

Cerebrospinal Fluid (CSF) Leak

  • Clear Rhinorrhea or Otorrhea
  • From Tear in Dura Creating Communication Between Subarachnoid Space & Sinuses/Middle Ear
  • Most Resolve Spontaneously within 7 Days
  • Dx: Tau Protein (β2-Transferrin)
  • Tx: Observation
    • If Persistent: Lumbar Drain or Surgery

Racoon Eyes 3

Battle Signs 4

Facial Fracture

Frontal Sinus Fracture

  • Strongest Facial Bone (Thick Cortical Bone)
  • Tx Options:
    • No Displacement or CSF Leak: Observation
    • Anterior Table Displaced with No Communication: ORIF
    • Posterior Table Displaced, Communication or CSF Leak: Obliteration of Sinus

Nasal Fracture

  • Most Common Facial Fracture Site
  • Edema Can Obscure Anatomy
  • Repair Timing:
    • First 3 Hours (Before Edema Onset)
    • After 3-10 Days (After Edema Resolution)
  • Septal Hematoma
    • Can Cause Pressure Necrosis
    • Must Always Preform an Intranasal Examination
    • Tx: I&D with Packing

Frontal Sinus Fracture 5

Nasal Fracture 6

Orbital Fracture

  • Emergencies:
    • Oculocardiac Reflex (Aschner Phenomenon)
      • Nausea & Bradycardia/Asystole Due to Extraocular Muscle Entrapment
      • Reflex Between Trigeminal Nerve & Vagus
    • Roof Fracture
  • Orbital Blowout Fracture: Fracture Involving Orbital Floor/Medial Wall
    • “Pure” Orbital Blowout – Orbital Rim Preserved
    • “Impure” Orbital Blowout – Orbital Rim Fractured
  • Treatment Timing:
    • Emergency: Immediate Repair
    • Nonemergent: Delayed Repair < 2 Weeks (Allow Edema to Decrease)
  • Orbital Compartment Syndrome
    • Presentation: Markedly Increased Intraocular Pressure, Impaired Vision & Eye Movement
    • Tx: Lateral Canthotomy to Decompress

Orbital Blowout Fracture 7

Zygomaticomaxillary Complex (ZMC) Fracture

  • “Tripod” Fracture
    • Zygomatic Arch
    • Lateral Orbital Wall
    • Anterior Maxilla
  • “Quadripod” Fracture
    • Tripod + Orbital Floor
  • Tx: Cosmetic ORIF

Mandible Fracture

  • Most Common in Blunt Trauma
  • Frequently Multiple
  • Most Common Sx: Malocclusion (Imperfect Positioning of Teeth Upon Closure)
  • Healing Ability
    • “Favorable” – Inferior & Anterior Angled
    • “Unfavorable” – Inferior & Posterior Angled
  • Tx: ORIF or Intermaxillary Fixation (IMF)
    • Most Important Factor: Accurate Alignment of Upper/Lower Teeth

ZMC & Mandible Fracture 8

Le Fort Fractures

  • Classification: Mn
    • Type I: Transverse Maxillary Fracture
    • Type II: Oblique Maxillary/Nasal Fracture
      • Most Common (60%)
    • Type III: Orbital Walls
  • Tx: Early Surgical Repair (Before Bony Resorption and Fibrous Ingrowth)
    • Goal: Restore Facial Projection, Height & Proper Occlusion
    • Options:
      • Ex-Fix
      • ORIF
      • Intermaxillary Fixation (IMF)
      • Suspension Wires

Le Fort Fractures; (a) Type I, (b) Type II, (c) Type III 9

Other Issues

Epistaxis

Laceration

  • Scalp
    • Copiously Irrigate & Repair
    • Do Not Need to Remove Hair
  • Ear
    • Suture Through Cartilage
  • Lip
    • Most Important Principle: Align Vermillion Border
  • Tongue
    • Minor Will Generally Heal Without Intervention
    • Repair Lingual Artery if Deep & Transected

Facial Nerve Transection

  • Most Common Cause: Temporal Fracture at Geniculate Ganglion
  • Tx:
    • Medial to Lateral Canthus of Eye: Conservative Management
      • Likely to Recover by Arborization
    • Lateral to Lateral Canthus of Eye: Surgically Repair

Auricular Hematoma

  • Definition: Hematoma of the Cartilaginous Auricle (Outer Ear)
  • Most Common After Blunt Trauma from Sports (Wrestling, Rugby, Boxing)
  • Risk for Cauliflower Ear (Calcification/Fibrocartilage Overgrowth)
  • Treatment:
    • Early Hematoma: Aspiration or I&D
      • Aspiration Generally Preferred if Small (< 2 cm) or Early (< 24-48 Hours)
      • Goal: Prevent Cauliflower Ear
    • Late Cauliflower Ear: Resection or Reconstruction

Stensen’s Duct Laceration

  • Presentation: Painful Parotid Atrophy & Fascial Asymmetry
  • Tx: Repair Over Stent

Facial Laceration of the Vermillion Border 10

Auricular Hematoma 11

Mnemonics

LeFort Fracture Classification

  • 1-2-3: Speak No Evil, See No Evil, Hear No Evil
  • *Not Exact Order of Original 3 Wise Monkeys Maxim

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