Tag Archives: facial fracture

What You Need To Know About Frontal Sinus Fractures

Fracture of the frontal sinus is less common than other facial injuries, but can be more complex to deal with, both in the shorter and longer terms. These are generally high energy injuries, and facial impact in car crashes is the most common mechanism. Fists generally can’t cause the injury, but blunt objects like baseball bats can.

Here’s the normal anatomy:

sinus-fracture-treatment

 

Source: www.facialtraumamd.com

There are two “tables”, the anterior and the posterior. The anterior is covered with skin and a small amount of subcutaneous tissue. The posterior table is separated from the brain by the meninges.

Here’s an image of an open fracture involving both tables. Note the underlying pneumocephalus.

frontal_sinus1

A third of injuries violate the anterior table, and two thirds violate both. Posterior table fractures are very rare. A third of all patients will develop a CSF leak, typically from their nose.

These fractures may be (rarely) identified on physical exam if deformity and flattening is noted over the forehead. Most of the time, these patients undergo imaging for brain injury and the fracture is found incidentally. Once identified, go back and specifically look for a CSF leak. Clear fluid in the nose is, by definition, CSF. Don’t waste time on a beta-2 transferring (see below).

If a laceration is clearly visible over the fracture, or if a CSF leak was identified, notify your maxillofacial specialist immediately. If more than a little pneumocephalus is present, let your neurosurgeon know. Otherwise, your consults can wait until the next morning.

In general, these patients frequently require surgery for the fracture, either to restore cosmetic contours or to avoid mucocele formation. However, these are seldom needed urgently unless the fracture is an open fracture with contamination or there is a significant CSF leak. If in doubt, though, consult your specialist.

Related posts:

What You Need To Know About Frontal Sinus Fractures

Fracture of the frontal sinus is less common than other facial injuries, but can be more complex to deal with, both in the shorter and longer terms. These are generally high energy injuries, and facial impact in car crashes is the most common mechanism. Fists generally can’t cause the injury, but blunt objects like baseball bats can.

Here’s the normal anatomy:

sinus-fracture-treatment

 

Source: www.facialtraumamd.com

There are two “tables”, the anterior and the posterior. The anterior is covered with skin and a small amount of subcutaneous tissue. The posterior table is separated from the brain by the meninges.

Here’s an image of an open fracture involving both tables. Note the underlying pneumocephalus.

frontal_sinus1

A third of injuries violate the anterior table, and two thirds violate both. Posterior table fractures are very rare. A third of all patients will develop a CSF leak, typically from their nose.

These fractures may be (rarely) identified on physical exam if deformity and flattening is noted over the forehead. Most of the time, these patients undergo imaging for brain injury and the fracture is found incidentally. Once identified, go back and specifically look for a CSF leak. Clear fluid in the nose is, by definition, CSF. Don’t waste time on a beta-2 transferring (see below).

If a laceration is clearly visible over the fracture, or if a CSF leak was identified, notify your maxillofacial specialist immediately. If more than a little pneumocephalus is present, let your neurosurgeon know. Otherwise, your consults can wait until the next morning.

In general, these patients frequently require surgery for the fracture, either to restore cosmetic contours or to avoid mucocele formation. However, these are seldom needed urgently unless the fracture is an open fracture with contamination or there is a significant CSF leak. If in doubt, though, consult your specialist.

Related posts:

EAST 2016: (F)utility Of Antibiotic Use In Facial Fractures

The majority of
trauma patients presenting with facial fractures are managed without surgery.
Dogma in the facial fracture literature indicates that antibiotics should be
administered for some period of time, typically 7-10 days, for fractures that
involve one of the sinuses.

Although this idea
and practice have been around for a long time, there is no good literature out
there to support it
. Most medical professionals are now aware of the downside
to giving unnecessary antibiotics, including allergic reactions, C. Diff infections,
and promotion of antibiotic resistance.

A group at Geisinger
Medical Center in Danville, PA, performed a four-year retrospective review of
their registry data involving nonoperatively managed facial fractures. They
stratified their patients into three groups: no antibiotics, brief antibiotics
(1-5 days), and prolonged antibiotics (>5 days). A total of 289 patients
were studied.

Here are the factoids:

  • 17% received no antibiotics, 22% received a short course, and 61% got them
    for more than 5 days (!)
  • There were no soft tissue infections in any of the groups
  • There was 1 C. Diff infection, which occurred in the prolonged
    antibiotic group. This was not statistically significant.

Bottom
line: Granted, this was a small, retrospective study. But absolutely no difference
in soft tissue infections was seen, and fear of infection is the usual
justification for the use of antibiotics in these patients. A single case of C.
Diff colitis was noted, and it just happened to occur in the prolonged
antibiotic group. It’s time that we consider abandoning the blanket use of
antibiotics for facial fractures involving the sinuses.

Reference: Utility of
prophylactic antibiotics for non-operative facial fractures. EAST 2016 Poster
abstract #11.

The Tripod Fracture

The tripod fracture (officially known as the zygomaticomaxillary complex fracture, and sometimes called a malar fracture) is the most common one seen after trauma. Fundamentally, the zygoma is separated from the rest of the face in a tripod fracture.

As you might imagine (tripod fracture), there are three components to this fracture. The first is a fracture through the zygomatic arch (1). Next, the fracture extends across the floor of the orbit and includes the maxillary sinus (2). Finally, the fracture includes the lateral orbital rim and wall (3). 

Extraocular muscles may become trapped in the fracture line, leading to diplopia. It is very important to do a good eye exam to try to detect entrapment. The infraorbital nerve also passes through the orbital floor and may be injured, leading to numbness along the lower eyelid and upper lip.

Nondisplaced fractures are treated symptomatically and reevaluated after a week or so to see if surgery would be beneficial. Displaced or symptomatic fractures require early open reduction. The pictures below show the anatomy of these fractures. They are derived from teaching materials provided by the Radiology Department at the University of Washington.

image

image

The Tripod Fracture

The tripod fracture (officially known as the zygomaticomaxillary complex fracture, and sometimes called a malar fracture) is the most common one seen after trauma. Fundamentally, the zygoma is separated from the rest of the face in a tripod fracture.

As you might imagine (tripod fracture), there are three components to this fracture. The first is a fracture through the zygomatic arch (1). Next, the fracture extends across the floor of the orbit and includes the maxillary sinus (2). Finally, the fracture includes the lateral orbital rim and wall (3). 

Extraocular muscles may become trapped in the fracture line, leading to diplopia. It is very important to do a good eye exam to try to detect entrapment. The infraorbital nerve also passes through the orbital floor and may be injured, leading to numbness along the lower eyelid and upper lip.

Nondisplaced fractures are treated symptomatically and reevaluated after a week or so to see if surgery would be beneficial. Displaced or symptomatic fractures require early open reduction. The pictures below show the anatomy of these fractures. They are derived from teaching materials provided by the Radiology Department at the University of Washington.